CMS Introduces X Modifiers to Replace the 59 Modifier

By: CLMA Headquarters on Dec 16, 2014

Issue:
CMS is creating four new modifiers to define subsets of the -59 modifier, which is the modifier used to
define a distinct procedural service. CMS has issued Transmittal 1422 which creates XE, XS, XP and
XU modifiers. The -59 can still be used, but only when one of the four new modifiers does not apply.
Scope:
This change will impact every laboratory that submits claims to Medicare.
Details:
The -59 modifier is often used to bypass the National Correct Coding Initiative (NCCI) edits and is the
most widely used modifier. In the transmittal, CMS states that the -59 modifier is associated with
considerable abuse and high levels of audit activity, leading to reviews, appeals and civil fraud and abuse
cases. They state the primary problem with the -59 modifier is that it is defined for use in a wide variety
of circumstances. They therefore are supplementing it with four new more distinctive modifiers, starting
on January 1, 2015.
The four replacement modifiers are:

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

We have reached out to CMS to clarify the usage of these modifiers as they relate to laboratory claims.
They have not yet responded to our request for clarification. At this time, this is how the CLMA
Legislative, Compliance and Regulatory Committee (LCRC) understand the usage of these modifiers. If
CMS does respond to our query, and the information below changes, we will update this briefing.
The XE and XP will generally not be used for laboratory claims.
The XS modifier is to be used when the same laboratory procedure is performed on more than one body
site. Examples of this are wound cultures from separate parts of the body. Another example is skin
biopsies from multiple sites.
The XU modifier is to be used when there multiple units of the same CPT code, but the laboratory
procedures are different. The best example of this is CPT 86003 which is used for allergen testing. All
allergens use the same CPT, but the test can be for nuts, milk, grass, cats, etc. These are different tests that
all use the same CPT code. Another example is an antibody test where an IgG and an IgM can be tested,
but there is only one CPT code available. Once again, they are separate, distinct tests which use the same

CPT code. CPT 82784, Gamma globulin (immunoglobulin); IgA, IgD, IgG, IgM, each is another example
of this scenario.
CMS states that it will be improper to include both the -59 and an X modifier on the same claim,
The -91 modifier is the other modifier that laboratories use. Its usage will not change. It will continue to
be used for repeat laboratory testing. CMS has defined this as the same test repeated in the same day or a
test that is a component of a panel being repeated on the same day.
Impact:
Laboratories must start using the new X modifiers in January or risk increased denials and manual
audits.
Actions:
CLMA members need to confirm with their billing and coding staff that they are aware of the new
modifiers and their proper usage.