Modifier 59, distinct procedure/service

Modifier 59 is used to identify procedures/services that are commonly bundled together but are appropriate to report separately under some circumstances. A health care provider may need to use modifier 59 to indicate that a procedure or service was distinct or independent from other services performed on the same day. This commonly means a different location, different anatomical site, and/or a different session. For guidance on proper use of modifier 59, see your CPT Manual or the CMS Modifier 59 download.

Documentation requirements

Although modifier 59 may be appended to a claim line on first submission, this does not guarantee reimbursement of these services. Documentation must support a distinct procedural service.

• Providers must maintain adequate documentation in the medical record to support the use of modifier 59 for distinct services.
• We require that you submit medical records with the initial professional claim when using modifier 59 with the codes listed below.
• Addenda or amendments to the documentation will not be accepted after a claim has been denied.
• If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier 59 for that claim line, we will require medical records in order to process the corrected claim.

Modifier XE, XS, XP & XU, separate or distinct services

These modifiers help identify distinct services that are typically considered inclusive to another service. Using these modifiers results in more accurate coding that better describes the procedural encounter.

These modifiers, collectively known as -X {ESPU}, will be accepted for all lines of business on both professional and facility claims.

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.

These modifiers are appropriate for National Correct Coding Initiative (NCCI) procedure-to-procedure edits only. See the modifier fact sheets from CMS, bottom of page, for more guidance.

Use of these modifiers vs. modifier 59

Do not use one of these modifiers with modifier 59 on the same claim line. According to CPT guidelines, modifier 59 should be used only when no other descriptive modifier explains why distinct procedural circumstances exist. Therefore, these new modifiers should be used instead of modifier 59 to describe why a service is distinct.

The CPT definition for modifier 59 has also been revised with a notation that references using these Level II HCPCS modifiers. 

We will continue to accept modifier 59 when the XE, XS, XP or XU modifiers do not accurately describe the encounter. Documentation must support use of modifiers.

Documentation requirements

As always, providers must maintain adequate documentation in the medical record.

• Documentation must support the modifier use for separate services.
• Although one of these modifiers may be appended to a claim line on first submission, this does not guarantee reimbursement for these services.
• Medical records may be required to validate use of modifier.
• Addenda or amendments to the documentation will not be accepted after a claim has been denied.
• If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier XE, XS, XP, or XU for that claim line, we will require medical records in order to process the corrected claim.

Codes that require medical records with the initial claim

Submit medical records with an initial professional claim when using modifier 59 or an X{ESPU} modifier with these codes.

Cardiovascular system:

• 36215-36218
• 36901
• 36902
• 38220

Digestive system:

• 44005
• 45378
• 45380
• 45381
• 49000
• 49010
• 49320

Integumentary system:

• 11055-11057
• 19120
• 19125
• 19301
• 19303
• 19307
• 19316
• 19318
• 19325
• 19328
• 19330
• 19340
• 19357
• 19361
• 19370
• 19371
• 19380

Medicine:

• 92960
• 93975
• 93976
• 96160
• 96161
• 97760
• 99173

Musculoskeletal system:

• 20670
• 20680
• 22224
• 22505
• 22551
• 22552
• 22554
• 22585
• 22600
• 22610
• 22612
• 22614
• 22630
• 22633
• 22634
• 22800
• 22802-22804
• 22830
• 22842
• 22845
• 22846
• 22848
• 22850-22852
• 22855
• 22867
• 22868
• 23430
• 23700
• 24300
• 25259
• 26340
• 27570
• 27860
• 28110
• 28230
• 28232
• 28270
• 28272
• 28310
• 28135
• 28725
• 29805-29807
• 29819-29825
• 29870
• 29884

Nervous and ENT systems: