Medicare Compliance & Reimbursement

Use new X{EPSU} modifiers with caution.

The Centers for Medicare & Medicaid Services (CMS) and the MACs have been slow to give specific guidance on Medicare’s new “X{EPSU}” modifiers. If you are eager to start reporting these modifiers, read on for advice on how to use them correctly.

Some coders report that they’ve already received denials for the new modifiers, which were meant to take some of the strain off of the use of modifier 59 (Distinct procedural service). WPS Medicare issued fact sheets recently for modifiers XE, XP, XS and XU (www.wpsmedicare.com/j8macpartb/resources/modifiers/), but they don’t offer any more information than CMS’s original advice on the issue. Only Part B MAC Noridian has appeared to issue hard facts on the modifiers, which are buried within a general modifier FAQs on the payer’s website. We’ve extracted information from Noridian’s FAQ answers below so Part B practices can get some insight into the appropriate usage of these modifiers.

Differentiate the New Modifiers From Each Other

When asked to explain the difference between modifier XE (Separate encounter) and modifier XS (Separate structure), Noridian advised that XE involves a separate encounter, which “means at two different times; e.g. once in the morning and again in the afternoon as an example.” Modifier XS, on the other hand, refers to a procedure performed on a “separate structure or organ.” So think of XE is a different time of day and XS as a different organ.

Surprising: Modifier XS does not, however, apply to cases where the practitioner addresses a separate incision/excision, separate lesion, or separate injury. Modifier XS “is only for separate organ or structure,” Noridian says. “If providers have any of these other situations, continue billing with modifier 59,” the payer notes.

When it comes to separating modifier XP from the pack, Noridian explains that modifier XE is only applicable if the same provider is performing both services, but at different times of day. Modifier XP (Separate practitioner), however, should only be used if different providers are performing the two services.

Modifier 59 May Still Be Best

In some cases, the X{EPSU} modifiers won’t apply at all. For example, if an ophthalmologist performs a tear osmolarity (83861) on both eyes during the same visit, “No modifier is needed,” Noridian says. “Per the CPT® book, when both eyes are tested, bill CPT® 83861 with number of service 2” instead of using any modifiers.

You’ll also find situations when modifier 59 is still your best option. Noridian points to the example of the physician performing two lab panels (such as 80069 and 80076). In this case, you’ll “continue to use modifier 59,” Noridian says. “None of the subset codes will apply.” The same is true if the surgeon removes a polyp via snare and another polyp by cold biopsy during colonoscopy. This would warrant modifier 59 as well, the MAC advises.

Use Just One of the Modifiers

Although you might want to cover your bases and report more than one of the new modifiers at a time, that won’t work. Noridian advises that you can only use one modifier on each line, and you should pick “the one that fits best.”

Resource: To read Noridian Medicare’s modifier FAQs, visit https://med.noridianmedicare.com/web/jeb/education/event-materials/global-surgery-modifiers-q-as.