This policy addresses guidelines for services considered adjunctive to a basic service and systems logic that enforces code combinations when Modifiers 25, 59, XE, XP, XS or XU are present on the claim based on CMS NCCI and/or Blue Cross Blue Shield of North Dakota (BCBSND) direction.
Modifier 25 – Used to report significant separately identifiable evaluation and management (E & M) services by the same physician or other qualified health care professional on the same day of the procedure or other service.
Modifier 59 – Used to report a distinct procedural service. Generally, modifier 59 is only applicable to those code combinations noted in the Correct Coding Initiative (CCI) code list with a modifier indicator of 1, which specifies the services are distinct and separate and thus allowed.
Modifiers XE, XP, XS and XU – Used to report services that are distinct because they occurred as a part of a separate encounter, separate practitioner, were done to a separate organ/structure, or it is unusual in that it does not overlap usual components of the main service.
Modifiers 59, XE, XP, XS and XU
CMS NCCI edits indicate when the presence of an override modifier is permitted to bypass code combination logic, and to allow separate reimbursement for both the combination code and the component code. When NCCI indicates code combinations that are never allowed separate reimbursement for both procedures, our reimbursement will be limited to the allowance of the higher paying procedure of the code combination. In these instances, modifiers 59, XE, XP, XS and XU will not be allowed to override the code combination. This involves claims for the same patient, same date of service and the same provider specialty.
Outpatient facility claims billed on the UB-04 Claim Form must use modifier 59 to bypass payment consolidation for separate procedures. Modifiers XE, XP, XS and XU will not bypass consolidation for separate procedures processed under Enhanced Ambulatory Patient Groups (EAPGs).
Modifier 25 is not to be used in situations when the services provided are a part of the usual pre/post care related to the procedures(s). Modifier 25 represents that the E & M service was performed for reasons unrelated to other procedure(s) performed on the same day.
When a preventative E & M and another E & M service with the 25 modifier is submitted for the same date of service, BCBSND will consider only the preventative E & M. The remaining E & M with the 25 modifier will be denied as provider liable.
Modifiers 25, XE, XS, XP or XU allows assignment of a medical visit for separate payment when reported with a significant procedure on outpatient facility claims billed on the UB-04 Claim Form processed under EAPGs. .
Refer to the following Reimbursement Policies for additional information:
Added reference for how to use modifiers for facility outpatient claims processing with EAPG pricing.