Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code. CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS) and provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

  • To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery
  • To indicate that a procedure was performed bilaterally or to designate laterality (LT/RT)
  • To report multiple procedures performed at the same session by the same provider. • To report only the professional component or only the technical component of a procedure.
  • To designate performance on a specific part of the body (ie T3=L foot 4th digit.)

More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes.

Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational but all are typically necessary to avoid denials.

Modifiers are not intended to be used to report services that are “similar” or “closely related” to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.

Modifier Definitions: Modifier 59 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 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 explains 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 day, see modifier 25.

Effective for dates of service January 1, 2015 and following, CMS established four new HCPCS modifiers to define subsets of the -59 modifier, to better define the “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU. (collectively referred to as -X{EPSU}. Where:

  • 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 or 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.

These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier and since The -X{EPSU} modifiers are more selective versions of the -59 modifier, it would be incorrect to include both the 59 modifier and a subset modifier on the same line.

Different Organs/Contiguous Structures:: From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example: Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.”

Incorrect use of modifiers XE, XP, XS, XU, or 59:

  • Procedures in the same anatomical site (e.g. digit, breast, etc.), even with incision lengthening or contiguous incision.
  • CPT identified “separate” procedures performed in the same session, same anatomic site, or orifice. • Laparoscopic procedure converted to open procedure.
  • Incisional repairs are part of the global surgical package, including deliveries and cosmetic improvement of a previous scar at the location of the current incision.
  • Contiguous structures in the same anatomic site or organ system. (See Coding Guidelines “Different Organs/Contiguous Structures” and CCI Policy Manual, chapter 1.

**** Modifier XP should not be used to identify two providers of the same specialty in the same clinic to bypass global surgery package rules, new-patient visit edits, or other same-specialty rules.