Modifiers 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. 

See modifier 59 information in this Manual.

Priority Health will continue to accept modifier 59 when the X{ESPU} 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 XU, 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 an X{ESPU} modifier with these codes.

April 1, 2017, changes: Codes listed in bold are added, and codes in [bracketed italic] removed.

Cardiovascular system:

  • 36215-36218
  • 36901
  • 36902
  • 38220

Digestive system:

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

Integumentary system:

  • 11055-11057
  • 19120
  • 19125
  • 19260
  • [19290, 19291, 19295]
  • 19301
  • 19303
  • 19307
  • 19316
  • 19318
  • 19325
  • 19328
  • 19330
  • 19340
  • 19357
  • 19361
  • 19370
  • 19371
  • 19380

Medicine:

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

Musculoskeletal system:

  • [20600, 20604-20606, 20610, 20650]
  • 20670
  • 20680
  • [22214]
  • 22224
  • [22425]
  • 22505
  • [22520, 22521-22524]
  • 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:

  • 63005
  • 63012
  • 63030
  • 63035
  • 63042
  • 63045-63048
  • 63055-63057
  • 63075
  • 63076
  • 63081
  • 63082
  • 67105
  • 69210
  • 69990 

Radiology:

  • [76942]

Urinary/reproductive systems:

  • 52000
  • 52310
  • 57100
  • 57268
  • 58555
  • 58660

Additional information is available in the MLM Matters article.