Gastroenterology Coding Alert

Question: Is modifier 59 still valid as modifier for colonoscopy CPT® codes 45380 and 45385? What is the XS modifier? Can the new X(EPSU) series modifiers be used for all insurances or just for Medicare claims?

California Subscriber

Answer: Yes. The modifier 59 (Distinct procedural service) is still applicable for 45380 (Colonoscopy, flexible; with biopsy, single or multiple) and 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) in Medicare. However, this modifier can be used only in absence of a more definitive X(EPSU) modifier to use. The XS modifier represents a separate structure. Depending on your documentation, the XS modifier may be the appropriate modifier to use in your scenario. 

Many private insurance companies are using these new modifiers like UHC, BCBS, PriorityHealth. Aetna and Cigna have yet to say much about the new modifier series. Please check the policies of your individual payer before using these modifiers.

CMS faces multiple issues when dealing with claims reporting modifier 59. The agency is attempting to solve those issues by introducing four new “X” modifiers that will replace modifier 59 in some instances for claims submitted to CMS. They are:

• XE: Separate encounter (A service that is distinct because it occurred during a separate encounter)
• XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure)
• XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner)
• XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service).

According to the CMS perspective,Modifier 59 can be used to separate CCI (Correct Coding Initiative) edits, but that’s not the only reason it’s available. According to Transmittal R1422, CMS states that many providers misuse modifier 59 for this purpose, leading it to be the source of a projected one-year error rate of $770 million.

CMS points out the following three common reasons that people use modifier 59, along with the associated error odds, according to MLN Matters article MM8863, issued on Aug. 15:

• Infrequently used to identify a separate encounter, typically used correctly
• Less commonly utilized to define a separate anatomic site, less often used correctly
• Commonly used to define a distinct service, but frequently done so incorrectly.

The transmittal said that these new modifiers do not cover all aspects when the 59 might be used so you can still use the 59 modifier if you think it fits the situation better than these four alternatives. However, I think that using the 59 modifier when one of the X codes doesn’t apply may create red flags since there should be few instances when something does not fall under one of these four codes.”