Consider you completed two procedures on the same patient on the same day. All of these services are valid and separately payable. But the payer’s system says there is only payment for One service. There needs to be a modifier that shows these services were done individually.
There are two modifiers that are going to work here. Those modifiers are 59 and XS. They have very similar purposes but are not the same. The first is a catch-all. The second is a specific option for different anatomical sites. This article covers exactly when to use each, how they vary, and what documentation protects you when the auditor calls.
What are these modifiers for?
Modifiers 59 and XS
Modifiers 59 and XS exist to bypass bundling edits. Bundling edits are based on the national correct coding initiative (NCCI) for Medicare. NCCI identifies pairs of codes that should not be billed together. In many cases, the service that is being coded is part of another procedure or service. For instance, a biopsy may be included in an excisional procedure since it is part of the overall excision process.
Sometimes, however, two procedures that could be bundled are actually different services. The patient had two different skin lesions. Each of the skin lesions were treated with a separate modality. A biopsy was done on One skin lesion and a removal was done on a second skin lesion. Although these services are provided within the same time frame, they are not a part of the same service. The modifiers inform the payer that these services are individualized.
Modifier 59 is defined as a “distinct procedural service.” That means that this modifier is applied when a service is distinct and separate from other services that were rendered on the same date. That includes a different location, session or anatomic site.
Modifier XS is more precise. Modifier XS represents “separate structure.” This modifier is used when a service is separated as it is being performed on a different organ or structure. Therefore, if you are doing Two things on Two different sites, then XS is your modifier.
The critical thing to understand is that 59 is a modifier of last resort. CPT recommends that 59 be utilized only after no more specific modifier can be utilized. CMS added the X modifiers in 2015 to offer more options than 59.
How does modifier 59 and XS differ?
Specificity makes up the major distinction between modifier 59 and XS.
To utilize modifier 59, consider the following:
- these services could have been bundled together but represent individualized services.
- no other modifier (XS, XE, XP, XU) adequately describe your services.
- these services could be due to the differing sessions, sites or different procedures.
To utilize Modifier XS, consider the following:
- these services represent individualized services because of the differing organs or structures.
- these services represent individualized services because of the differing anatomical sites.
This is a true example from gastroenterology. Colonoscopy with snare polypectomy in ascending colon and biopsy in transverse colon. These are Two different lesions and therefore the second procedure (biopsy) was assigned with Modifier XS indicating it was performed at a different anatomic site.
If you remove Two suspicious breast lesions on the left side of the chest (breast) and you want to override an edit, modifier 59 would be correct to show distinct service. Remember that modifiers XS, XE, XP, and XU are more specialized than modifier 59. Never place both modifier 59 and an x modifier on the same line.
When would you utilize Modifier XS?
Utilize Modifier XS when you want to show that the service is distinct because it was performed on a different organ or structure. According to texas medical association (TMA), if you provide procedural services at different anatomic sites and cannot describe the services with a more specific modifier such as RT, lt, or E1-E4, then use Modifier XS. Here are three examples of how to utilize Modifier XS clinically:
Example #1: Two separate lesions; Two separate locations; all services performed on the same day.
A dermatologist destroyed actinic keratosis on the patients face and biopsied a separate lesion on the trunk. The biopsy is distinct because it is a separate structure. You should attach Modifier XS to the biopsy code.
Example #2: separate organ systems in same session.
A physician performs cardiac procedure and repairs lacerated hand. The hand repair is at a separate anatomic site from cardiac procedure. Use Modifier XS.
Example #3: multi-procedure services performed at different sites on same day of visit.
Screening colonoscopy becomes therapeutic. Provider removes polyp from ascending colon and takes biopsy from second lesion in transverse colon. Code biopsy with XS attached to show it was performed at a different anatomic site than polypectomy.
This is the most commonly occurring scenario. Provide code 45385 for snare polypectomy and code 45380 for biopsy. Attach XS to the biopsy code. The provider must document “random cold forceps biopsies of ascending and descending colon” in order to prevent immediate denial of claim.
The most commonly occurring scenario is that you need to assign code 45385 for the snare polypectomy and code 45380 for the biopsy. Add the XS modifier to the biopsy code. The provider must document “random cold forceps biopsies of ascending and descending colon” to preclude immediate denial of claim.
Example #4: chiropractic manipulation performed at different region.
If you are providing manual Therapy or massage (97124 or 97140) on area of body that was not being manipulated during chiropractic manipulation (98940-98943) then those services are at separate anatomic sites. You would add Modifier XS to indicate it was located at a different location than spinal manipulation (98940-98943).
The XS modifier is essentially your best friend when defining a separate site. If you are treating the same organ or region, and that treatment is a separate encounter, that is the XE modifier.
When will you use modifier 59?
You will use 59 when you need to denote a distinct procedural service but do not meet the specifics needed for other modifiers available. As stated above, it is a modifier of last resort. If your circumstances do not meet XS, XE or XP then 59 may be correct to identify as separate services.
Example #1: Two different lesions in same organ.
Patient has Two suspicious breast lesions on left side of chest. Surgeon excised both lesions. Since they are the same organ, XS does not apply but 59 is accurate to show as separate services.
Example #2: Therapy services which were not done at different anatomical sites.
CMS national correct coding initiative edit bundle physical medicine codes like manual Therapy (97140) and therapeutic activities (97530) for same visit or session. While they are distinct services, they are not always performed on separate structures. Use modifier 59 to show that this was a unique experience.
Example #3: when x modifier is incorrect.
If you have Two procedures which are different as a result of different sessions (XE), practitioners (XP), then use those modifiers. If none of the x modifiers will apply, use 59.
Documentation for Modifier XS and 59
In addition to slapping a modifier on a code and hoping for reimbursement, you cannot simply attach a modifier without documentation supporting its utilization. For both 59 and XS documentation must show why the service was different.
For XS documentation must show that the service was done on a different organ or structure. It must show different anatomical sites. With regard to colonoscopy, documentation must note specific location of each polyp (i.e., ascending colon or transverse colon) and method (i.e., snare or cold forcep).
With regard to modifier 59 documentation must support a different session, procedure, site, separate incision, separate lesion, or separate injury.
Without documentation claims with modifiers are targets for denial. The modifier can be used to bypass an edit on claim, but you must have evidence for that claim submission. Many payers demand original documents submitted prior to claim adjudication when submitting claims with modifier like 59.
Common Billing and Coding Errors
Using XS As Default Option for All Distinct Services
XS only refers to separate structures. If you use it for other reasons than it will automatically deny your claim. Only use XS when you want to define separate structures.
Using Modifier 59 Instead Of XS
Both modifiers will allow you to bypass bundling edits but they do not function similarly. Payers generally prefer x-modifier because they are more specific. Medicare requests you to use x-modifier instead of 59 every time possible. If you chose to use 59 instead of XS you could receive denial notice for your claim or your claim could be sent for audit review.
Adding Either Modifier to Evaluation and Management Services
Do not add either modifier 59 or XS to evaluation and management (E&M) codes as they should not be used with E&M codes with procedure service provided in conjunction with E&M codes on the same day; use modifier 25 instead of either modifier.
Overuse Of Modifiers
Most or all codes placed onto claim with multiple services provided with modifier 59 or XS will cause problems with claims processing. Red flags occur with excessive use of modifier.
Failure To Document Separate Procedures
Documentation is key to successful claims submission! If record does not demonstrate that lesion was different from previous lesion; or did not demonstrate different sites; or did not demonstrate separate encounters; then modifier has failed to successfully pass audit! Be certain chart clearly demonstrates where each service was performed!
Which modifier payers prefer?
Not all payers treat 59 differently than XS.
Medicare prefers x-modifiers over all else.
CMS created them in 2015 for additional precision and has encouraged providers to replace all 59 with x modifier when applicable.
Commercial payers vary.
Some prefer x-modes while others accept 59.
Track your claim submissions for both modifiers to determine which payers reject which modifiers.
Commonly accepted practice is to report XS to Medicare and report 59 with commercial payers if that is what their computer program accepts! Create cheat sheets for billing personnel so they will know what modifiers to place on claims.
Final Takeaway
Modifier 59 and XS are both bypass mods to get reimbursed for distinct procedural services. The difference lies in specificity.
Modifier XS indicates that the service was performed at a different organ or structure! Modifier 59 can be considered as last resort as it is broad and less specific.
Do not use 59 when XS is the correct choice. Use the more specific modifier when the documentation supports it. Payer preference varies, but Medicare prefers the X modifiers, and many commercial carriers are moving in that direction.
Most importantly, documentation is king. Without solid notes, no modifier will save you from a denial or audit. When in doubt, let the documentation guide the modifier choice. If the record shows two different sites, use XS. If the record shows two distinct procedures at the same site, use 59.
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