XU Modifier

Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service

Instructions

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier XE is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. These procedures/services occur during a separate encounter.

This modifier was developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be used in lieu of modifier 59 whenever possible. Modifier 59 should only be used if no other more specific modifier is appropriate.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

Correct Use

  • Modifiers 59 or -XU are used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.
  • Modifiers 59 or -XU are used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.
  • Use of Modifiers 59 or -X{EPSU} do not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers 59 or -X{EPSU}. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Incorrect Use

  • Should not be appended to an E/M service
  • Should not be used inappropriately if the basis for its use is that the narrative description of the two codes is different
  • When another modifier is more appropriate (e.g. modifier 76 or 91)
  • Should not be used to bypass NCCI edits
  • Does not replace modifiers such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI

Modifiers 59 or -XU are used inappropriately if the basis for its use is that the narrative description of the two codes is different.

One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a "different procedure or surgery." The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be "separate and distinct." The provider should not use modifiers 59 or -XU for such an edit based on the two codes being "different procedures." However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifiers 59 or -X{ES} may be appended to indicate that they are different procedures on that date of service. Additionally, there may be limited circumstances sometimes identified in the National Correct Coding Initiative Policy Manual for Medicare Services when the two codes of an edit pair may be reported together with modifiers 59 or -X{ES} when performed at the same patient encounter or at the same anatomic site.

Example

Column 1 Code/Column 2 code - 34833/34820

  • CPT code 34833 - Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)
  • CPT code 34820 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

CPT code 34833 is followed by a CPT Manual instruction that states: "(Do not report 34833 in conjunction with 33364, 33953, 33954, 33959, 33962, 33969, 33984, 34820 when performed on the same side)." Although the CPT code descriptors for 34833 and 34820 describe different procedures, they should not be reported together for the same side. Modifiers 59 or -X{EPSU} should not be appended to either code to report the two procedures for the same side of the body. If the two procedures were performed on different sides of the body, they may be reported with modifiers LT and RT as appropriate. However, modifiers 59 or -X{EPSU} are used inappropriately if the basis for their use is that the narrative description of the two codes is different.

Reminders

Records must evidence a different session or patient encounter, different procedure or surgery, different site or organ system, or separate lesion, incision, excision, injury or area of injury

Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

Resources

 

Last Updated Apr 25 , 2023