In medical billing, Modifier 59 (procedural service) and XS (separate structure) are used to reflect a medical procedure that wasn’t bundled because it was performed on a different organ structure or a separate lesion.
However, both modifiers differ slightly from each other; XS is a bit specific, and 59 covers the broader distinct situations. This blog will explore important details about Modifier 59 and XS, their usage and benefits.
Understanding Modifiers 59 and XS
Modifiers XS refers to a separate structure or a service that was performed on a different organ/structure. In simple words, this modifier indicates that different medical services were given to a patient on the same day. Amongst both modifiers, XS is more specific while 59 is a general modifier.
Why Modifier 59 is Important
Insurance payers such as Medicare and other commercial providers instruct using these modifiers to avoid the risk of under and over billing.
The national correct coding initiative (NCCI) is the institute that governs the above-mentioned rules. According to these rules, some medical billing procedures are automatically bundled together for hassle-free billing.
Using Modifier 59 allows providers to
- Get quick reimbursement against the services provided.
- Reduce the risk of claim denials caused by inaccurate coding or documentation.
- Adhere to the payer regulations and remain compliant with CMS.
59 Distinct Procedural Services
Under specific situations, it’s important to indicate that a certain procedure was different from E/M services that were performed on the same day. Providers use modifier 59 to highlight that these services were other than E/M and not reported together.
In addition, the documentation must support the
- Different session
- Different procedure
- Separate lesion
- Organ system
- Separate Incision
The Evolution of Modifier 59 to XS
In order to understand the importance of modifier XS in the medical billing. Healthcare providers should know about its history. Earlier in medical billing, modifier 59 (District Procedural Service) was the primary modifier. Providers used it to indicate different services were performed on the same day.
At that time, CMS (Center for Medicare and Medicaid) identified that modifier 59 was often overused and misused. Therefore, CMS introduced X{EPSU} modifiers to provide more specific options:
- XE: Separate Encounter
- XS: Separate Structure
- XP: Separate Practitioner
- XU: Unusual Non-Overlapping Service
These modifiers were used in lieu of modifier 59 to ensure they accurately describe the circumstances of distinct independent medical procedures.
On the other hand, the modifier XS was introduced to highlight the situations where medical processes were performed on different organ systems.
When to use Modifiers 59 and XS
In medical billing, healthcare providers should use modifiers when necessary. Unwanted use of modifiers 59 and XS leads to claim denial and revenue loss.
· Different Anatomical Sites
in case a same doctor performs different medical procedures on two separate parts of the same body. Those services would be bundled, and providers will use modifier 59 to reflect the nature of services.
Example: A dermatology healthcare provider removes a lesion from the left arm and another one from the left leg.
· Multiple patient visits on same day
When a provider performs multiple procedures on the same day, modifier 59 must be used to clarify the type of treatment given. Suppose a patient got a knee injection and returned back for a hip joint injection.
· Distinct Procedure
Another scenario in which providers use modifier 59 is when the services are bundled together but billed separately because of their independent necessity. For instance, a doctor performs endoscopy before performing a therapeutic procedure.
· Unrelated Services
Sometimes, healthcare performs two different services in the same facility. Both services are not related to each other and require separate reimbursement.
How Does Modifier 59 and XS Impact Claim Processing
Both modifiers 59 and XS indicate that two bundled medical procedures are separate in nature; that require separate reimbursement. Although modifier XS is very specific, modifier 59 is general, claiming that service was different.
However, inaccurate or misuse of these modifiers can result in claiming denial and revenue loss. In addition, using XS modifier instead of 59 is preferred for clarity in understanding the services given to patients.
Final Thoughts
Modifier 59 and XS are used to indicate the services which are not bundled as they were performed on a different organ or body part. For instance, a doctor performed a procedure on right arm and again the patient needed treatment on the right leg.
NCCI governs these rules to ensure transparent service charges and reimbursement. Above we have explained when to use these modifiers and how their inaccurate use can lead you to claim denials and revenue loss.
Frequently Asked Questions
What differs Modifier 59 and XS?
XS is a specific type of modifier 59 that providers use when different healthcare services are performed on a different organ of the body.
What is the XS modifier used for?
Healthcare experts use HCPCS modifier XS (Separate Structure) to indicate a procedure is distinct because it was performed on a separate organ or anatomic structure.
What are the common modifier 59 Mistakes in the medical billing|?
Some common modifier 59 mistakes include overusing, not inappropriate use, lacking documentation, and failing to explain the necessity of modifier 59.
Modifier 59 vs XS, when to use both?
The use of modifier 59 or XS claims that separate services are given to same patients on different body organs. However, XS is technically more accurate than modifier 59.
How to accurately use modifier 59?
Providers should use modifier 59 with the code to explain that it’s a separate healthcare service from another code billed on the same day.
