Crystal's MCW Coder HubPage 1
CPT codes, descriptions, and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
What’s Changed?
Note: No substantive content changes.
MLN1783722 February 2025 CMS CENTERS FOR MEDICARE & MEDICAID SERVICES
Page 2
Table of Contents
- Definition of Modifiers -59, -XE, -XP, -XS & -XU 3
- Appropriate & Inappropriate Use of These Modifiers 4
- Rural Health Clinics & Federally Qualified Health Centers 7
- Examples of Appropriate & Inappropriate Use 7
- Resources 11
Page 3
The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when you shouldn’t report certain HCPCS or CPT codes together in all or most situations. These edits allow the following:
- For NCCI PTP edits with a Correct Coding Modifier Indicator (CCMI) of “0,” don’t report the codes together by the same provider for the same patient on the same date of service (DOS). If you do report the codes together on the same DOS, the Column 1 code is eligible for payment and Medicare denies the Column 2 code.
- For NCCI PTP edits that have a CCMI of “1,” report the codes together only in limited circumstances by using NCCI PTP-associated modifiers.
Refer to Chapter 1 of the [Medicare NCCI Policy Manual](Medicare NCCI Policy Manual) for general information about the NCCI program, NCCI PTP edits, CCMIs, and NCCI PTP-associated modifiers. One purpose of NCCI PTP edits is to prevent payment for codes that report overlapping services except where the services are “separate and distinct.”
Modifier -59 is an important NCCI PTP-associated modifier that physicians and providers often use incorrectly. This booklet will help you use this modifier correctly.
Definition of Modifiers -59, -XE, -XP, -XS & -XU
The CPT Manual defines modifier -59 as:
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M [Evaluation/Management] services performed on the same day. Modifier -59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 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.
However, when another already established modifier is appropriate it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best e-XPlains the circumstances, should modifier -59 be used.
Note: Modifier -59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
Don’t use modifiers -59, -XE, -XP, -XS, -XU, and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. Medical documentation must support the use of the modifier.
Page 4
Modifiers -XE, -XP, -XS, and -XU are valid modifiers. These modifiers give greater reporting specificity in situations where you used modifier -59 previously. Use these modifiers instead of modifier -59 whenever possible. Only use modifier -59 if no other more specific modifier is appropriate.
CMS allows modifiers 59, -XE, -XP, -XS, or -XU on Column 1 or Column 2 codes (see the related transmittal at CR 11168).
We define these modifiers as follows:
- -XE — “Separate encounter, a service that is distinct because it occurred during a separate encounter.” Only use -XE to describe separate encounters on the same DOS.
- -XP — “Separate practitioner, a service that is distinct because it was performed by a different practitioner.”
- -XS — “Separate structure, a service that is distinct because it was performed on a separate organ/structure.”
- -XU — “Unusual Non-Overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.”
Appropriate & Inappropriate Use of These Modifiers
- Use modifier -59 or -XS for different anatomic sites during the same encounter only when procedures which aren’t ordinarily performed or encountered on the same day are performed on:
- Different organs
- Different anatomic regions
- In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ
Modifiers -59 and -XS are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: * Are performed at different anatomic sites. * Aren’t ordinarily performed or encountered on the same day. * Can’t be described by 1 of the more specific anatomic NCCI PTP-associated modifiers - in other words, -RT, -LT, -E1-E4, -FA, -F1-F9, -TA, -T1-T9, -LC, -LD, -RC, -LM, or -RI. See Examples 1, 2, and 3 below.
Page 5
From an NCCI program perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. We created NCCI edits to prevent the inappropriate billing of lesions and sites that aren’t considered separate and distinct. Treatment of contiguous structures in the same organ or anatomic region doesn’t generally constitute treatment of different anatomic sites. For example:
- Treating the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site. See Example 4 below.
- Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. See Example 5 below.
- Only use modifier -59 or -XE if no other modifier more appropriately describes the relationship of the 2 procedure codes
Another common use of modifier -59 or -XE is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed during different patient encounters on the same day that can’t be described by 1 of the more specific NCCI PTP-associated modifiers - in other words, -24, -25, -27, -57, -58, -78, -79, or -91. See Example 7 below.
- Don’t use modifier -59 or -XU just because the code descriptors of the 2 codes are different
One of the common misuses of modifier -59 relates to the part of the definition of modifier -59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the 2 codes of a code pair edit describe different procedures, even though they may overlap. Don’t report the 2 codes together if they’re performed at the same anatomic site and same patient encounter because they aren’t considered “separate and distinct.” Don’t use modifier -59 or -XU to bypass a PTP edit based on the 2 codes being “different procedures.” See Example 8 below.
However, if you perform 2 procedures at separate anatomic sites or at separate patient encounters on the same DOS, you may use modifiers -59, -XE, or -XS to show that they’re different procedures on that DOS. Also, there may be limited circumstances sometimes identified in the Medicare NCCI Policy Manual when you may report the 2 codes of an edit pair together with modifiers -59, -XE, or -XS when performed at the same patient encounter or at the same anatomic site.
- Other specific proper uses of modifiers -59, -XE, or -XU
There are 3 other limited situations where you may report 2 services as separate and distinct because they’re separated in time and describe non-overlapping services even though they may occur during the same encounter.
Page 6
A. Using modifier -59 or -XE properly for 2 services described by timed codes provided during the same encounter only when they’re performed one after another. There’s an appropriate use for modifier -59 that’s applicable only to codes for which the unit of service is a measure of time (2 examples are: per 15 minutes or per hour). If you provide 2 timed services in separate and distinct time periods that aren’t mingled with each other (in other words, you complete 1 service before the next service begins), you may use modifier -59 or -XE to identify the services. See Example 9 below.
B. Using modifier -59 or -XU properly for a diagnostic procedure which is performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When you perform a diagnostic procedure before a surgical procedure or non-surgical therapeutic procedure and it’s the basis on which you decide to perform the surgical procedure or non-surgical therapeutic procedure, you may consider that diagnostic procedure to be a separate and distinct procedure if it: a. Occurs before the therapeutic procedure and isn’t mingled with services the therapeutic intervention requires. b. Clearly provides the information needed to decide whether to proceed with the therapeutic procedure. c. Doesn’t constitute a service that you would’ve otherwise required during the therapeutic intervention. See Example 10 below.
If the diagnostic procedure is an inherent component of the surgical procedure, don’t report it separately.
C. Using modifier -59 or -XU properly for a diagnostic procedure that occurs after a completed therapeutic procedure only when the diagnostic procedure isn’t a common, e-XPected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, you may consider that diagnostic procedure to be a separate and distinct procedure if it: a. Occurs after the completion of the therapeutic procedure and isn’t mingled with or otherwise mi-XEd with services that the therapeutic intervention requires. b. Doesn’t constitute a service that would’ve 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, don’t report it separately.
Using modifiers -59, -XE, -XP, -XS, or -XU doesn’t require a different diagnosis for each HCPCS or CPT coded procedure. On the other hand, different diagnoses aren’t adequate criteria for using modifiers -59, -XE, -XP, -XS, or -XU. The HCPCS or CPT codes remain bundled unless you perform the procedures at different anatomic sites or during separate patient encounters, or meet 1 of the other 3 scenarios described by A, B, or C above.
Page 7
Rural Health Clinics & Federally Qualified Health Centers
A single Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) visit constitutes more than 1 RHC or FQHC practitioner encounter on the same day, or multiple encounters with the same RHC or FQHC practitioner on the same day. It’s payable as 1 visit. This policy applies regardless of all of these:
- Length or complexity of the visit
- Number or type of practitioners seen
- Second visit is scheduled or unscheduled
- First visit is related or unrelated to the subsequent visit
An exception to this policy occurs when the patient, after the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day (for example, a patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the RHC or FQHC). In this situation only, the FQHC would use modifier -59 on the claim and the RHC would use modifier -59 or 25 to show the treatment qualifies for 2 billable visits.
The only other exceptions are:
- The patient has a medical visit and a mental health visit on the same day (2 billable visits)
- For RHCs only, the patient has an initial preventive physical exam (IPPE) and a separate medical, mental health visit, or both on the same day as the IPPE (2 or 3 billable visits)
Examples of Appropriate & Inappropriate Use
Example 1:
| Column 1 | Column 2 |
|---|---|
| CPT Code [[11102]] - Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion | CPT Code [[17000]] - Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettetment), premalignant lesions (eg, actinic keratoses); first lesion |
You may report modifier -59 or -XS with either the Column 1 or Column 2 code if you did the procedures at different anatomic sites on the same side of the body and a specific anatomic modifier isn’t applicable. If you did the procedures on different sides of the body, use modifiers RT and LT or another pair of anatomic modifiers. Don’t use modifier -59 or -XS.
Page 8
Using modifier -59 or -XS is appropriate for different anatomic sites during the same encounter only when procedures (that aren’t ordinarily performed or encountered on the same day) are performed on different organs or different anatomic regions, or in limited situations, on different, non-contiguous lesions in different anatomic regions of the same organ.
Example 2:
| Column 1 | Column 2 |
|---|---|
| CPT Code 47370 - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency | CPT Code 76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation |
Don’t report CPT code 76942 with or without modifiers -59, -XE, -XP, -XS, or -XU if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure 47370. Only report 76942 with modifiers -59, -XE, -XP, -XS, or -XU if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation.
Example 3:
| Column 1 | Column 2 |
|---|---|
| CPT Code 93453 - Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed | CPT Code 76000 - Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time |
Don’t report CPT code 76000 with or without modifiers -59, -XE, -XP, -XS, or -XU for fluoroscopy in conjunction with a cardiac catheterization procedure. You may report 76000 with modifiers -59, -XE, -XP, -XS, or -XU if you perform the fluoroscopy for a procedure unrelated to the cardiac catheterization procedure.
Example 4:
| Column 1 | Column 2 |
|---|---|
| CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion | CPT Code 11720 - Debridement of nail(s) by any method(s); 1 to 5 |
Page 9
Don’t report CPT codes 11055 and 11720 together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Don’t use modifiers -59, -XE, -XP, -XS, or -XU if you debride a nail on the same toe on which you pare a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint. You may report modifier -59 or -XS with code 11720 if you debride 1 to 5 nails and you pare a hyperkeratotic lesion on a toe other than 1 with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which you debride a nail.
Example 5:
| Column 1 | Column 2 |
|---|---|
| CPT Code 67210 - Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation | CPT Code 67220 - Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions |
Don’t report CPT code 67220 with or without modifiers -59, -XE, -XP, -XS, or -XU if you perform both procedures during the same operative session because the retina and choroid are contiguous structures of the same organ.
Example 6:
| Column 1 | Column 2 |
|---|---|
| CPT Code 29827 - Arthroscopy, shoulder, surgical; with rotator cuff repair | CPT Code 29820 - Arthroscopy, shoulder, surgical; synovectomy, partial |
Don’t report CPT code 29820 with or without modifiers -59, -XE, -XP, -XS, or -XU if you perform both procedures on the same shoulder during the same operative session. If you perform the procedures on different shoulders, use modifiers RT and LT, not modifiers -59, -XE, -XP, -XS, or -XU.
Example 7:
| Column 1 | Column 2 |
|---|---|
| CPT Code 93015 - Cardiovascular stress test using maximal or submaximal treadmill or bicycle e-XErcise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report | CPT Code 93040 - Rhythm ECG, 1-3 leads; with interpretation and report |
Page 10
You may report modifier -59 or -XE if you interpret and report the rhythm electrocardiogram (ECG) at a different encounter than the cardiovascular stress test. If you interpret and report a rhythm ECG during the cardiovascular stress test encounter, don’t report 93040 with or without modifier -59. You may report modifier -59 or -XE when you interpret and report the procedures in different encounters on the same day.
Example 8:
| Column 1 | Column 2 |
|---|---|
| CPT Code 34833 - Open iliac artery e-XPosure 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 e-XPosure 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) |
A CPT Manual instruction follows CPT code 34833, which states, “(Do not report 34833 in conjunction with 33364, 33953, 33954, 339-59, 33962, 33969, 33984, 34820 when performed on the same side).” Although the CPT code descriptors for 34833 and 34820 describe different procedures, don’t report them together for the same side. Don’t add modifiers -59, -XE, -XP, -XS, or -XU to either code to report 2 procedures for the same side of the body. If you performed 2 procedures on different sides of the body, you may report them with modifiers LT and RT as appropriate. However, modifiers -59, -XE, -XP, -XS, or -XU are inappropriate if the basis for their use is that the narrative description of the 2 codes is different.
Example 9:
| Column 1 | Column 2 |
|---|---|
| CPT Code 97140 - Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes | CPT Code 97750 - Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes |
You may report modifier -59 if you perform 2 procedures in distinctly different 15-minute time blocks. For example, you may report modifier -59 if you perform 1 service during the initial 15 minutes of therapy and you perform the other service during the second 15 minutes of therapy. As another example, you may report modifier -59 if you split the therapy time blocks by performing manual therapy for 10 minutes, followed by 15 minutes of physical performance test, followed by another 5 minutes of manual therapy. Don’t report CPT code 97750 with modifier -59 if you perform 2 procedures during the same time block. You may report modifier -59 when you perform 2 timed procedures in 2 different blocks of time on the same day.
Page 11
Example 10:
| Column 1 | Column 2 |
|---|---|
| CPT Code 37220 - Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty | CPT Code 75710 - Angiography, extremity, unilateral, radiological supervision and interpretation |
You may report modifier -59 or -XU with CPT code 75710 if you haven’t already performed a diagnostic angiography and you base the decision to perform the revascularization on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which you may report diagnostic angiography with an interventional vascular procedure on the same artery. You may report modifier -59 or -XU for a diagnostic procedure performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
Resources
- Medicare National Correct Coding Initiative (NCCI) Edits
- Medicare Benefit Policy Manual, Chapter 13, section 40.3
View the Medicare Learning Network® Content Disclaimer and Department of Health & Human Services Disclosure.
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
CPT only copyright 2024 American Medical Association. All Rights Reserved.