Tips for correct use of the -X{EPSU} modifiers

2014 08 29 09 35 55 499 Majchrzak Jeff 200

It may be old news that modifier 59 (distinct procedural service) is one of the most commonly used -- and misused -- modifiers, and that the U.S. Centers for Medicare and Medicaid Services (CMS) in late 2014 created what it calls the -X{EPSU} modifiers to identify specific subsets of modifier 59 more accurately:

  • XE: A service that is distinct because it occurred during a separate encounter
  • XS: A service that is distinct because it was performed on a separate organ or structure
  • XP: A service that is distinct because it was performed by a different practitioner
  • XU: An unusual nonoverlapping service (one that is distinct because it does not overlap usual components of the main service)

Modifiers connected to edits

The National Correct Coding Initiative (NCCI) includes procedure-to-procedure edits that identify -- with two modifier indicators (MIs) -- when two Healthcare Common Procedure Coding System (HCPCS) codes can and cannot be reported together. One function of these edits is to prevent payment for codes that report overlapping services except in those instances where the services are "separate and distinct."

Jeff Majchrzak of Panacea Healthcare Solutions.Jeff Majchrzak of Panacea Healthcare Solutions.

Codes identified with an MI of "0" should never be reported together by the same provider for the same beneficiary on the same date of service (DOS). If they are reported on the same DOS, the column 1 code is eligible for payment, but the column 2 code is ineligible and will be denied. Codes identified with an MI of "1" may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.

Consider modifier XU first

It is not old news that radiology coding professionals are still puzzled over how to use the above modifiers. The examples and explanations provided below may be of help, starting with a general rule of thumb.

Of the four new options, modifier XU (unusual nonoverlapping services) will be assigned frequently, specifically when diagnostic imaging is performed with a transcatheter therapy procedure, Panacea Healthcare's radiology consultants believe. For example:

  • 75625: Aortography, abdominal, by serialography, radiological supervision and interpretation (S&I)
  • 75716-XU: Angiography, extremity, bilateral, radiological S&I
  • 37224: Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

NCCI note: There is no edit of code 75625 with either code 75716 or 37224. Code 37224 includes injections that are not truly diagnostic in nature or intent. Assuming that the bilateral lower extremity imaging is indeed diagnostic, code 75716 would be considered the column 2 code to column 1 code 37224 and would need to be modified.

Another scenario might be when an MR stroke protocol is performed. In this case, a single MR and two MR angiographies (MRAs) are done. The areas typically studied are the neck (MRA) and head (MRI and MRA). Code assignments could look like this:

  • 70553: MR imaging (e.g., proton), brain (including brain stem); without contrast material, followed by contrast material and further sequences
  • 70546-XU: MRA, head; without contrast material, followed by contrast material and further sequences
  • 70549: MRA, neck; without contrast material, followed by contrast material and further sequences

NCCI note: There is no edit with CPT 70549 with either code 70546 or 70553. Code 70546 is considered to be the column 2 code to column 1 code 70553 and must be modified to legally bypass CCI edits.

Another possibility for the above scenario would be to use modifier XS instead of XU.

Sample scenarios and code assignments

Although not based on any CMS official guidance, my recommendation is to review each modality provided and determine three to five scenarios where multiple procedures might be performed on the same patient on the same DOS, whether it is the same encounter or not. Assign the codes as if the X-modifiers were not an option and then again using the X-subset series. Some may change and some may not.

Even though modifier XU may be a frequent choice, it will not be so 100% of the time, as shown in the examples below.

Example 1: Whole-body bone scan and bone SPECT

Code assignments:

  • 78306: Bone and/or joint imaging; whole body
  • 78320: Tomographic (SPECT)

NCCI note: There are no current CCI edits in place for these two codes.

Example 2: Transabdominal and duplex inflow/outflow procedure of the same anatomic areas

Code assignments:

  • 76700-XU: Ultrasound, abdominal, real-time with image documentation; complete
  • 93975: Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents, and/or retroperitoneal organs; complete study

NCCI note: CPT code 76700 is considered to be column 2 to column 1 code 93975 and must be modified to legitimately bypass CCI edits.

Example 3: Selective, diagnostic visceral angiogram of the celiac, right hepatic, and superior mesenteric arteries

Code assignments:

  • 75726 x 2: Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological S&I
  • 75774: Selective angiogram after basic, S&I
  • 36247: Selective catheter placement, arterial system; third-order catheterization
  • 36245-XS: Selective catheter placement, arterial system; first-order abdominal, pelvic, or lower extremity artery branch

NCCI note: Code 75726 has a medically unlikely edit (MUE) of 3 and an MUE adjudication indicator (MAI) of 1. Following this logic, the correct way to bill would be two separate line items of code 75726. First-order code 36245 is considered to be the column 2 code to column 1 (third-order) CPT 36247 and would be modified as these are separate vascular families.

Example 4: Chest x-rays, one is performed in the emergency room (one view), and later, on the same DOS, the patient is transported to the radiology department for a posteroanterior and lateral study (two views)

Code assignments:

  • 71020: Radiologic examination, chest; two views, frontal and lateral
  • 71010-XE: Radiologic examination, chest; single view, frontal

NCCI note: Code 71020 is column 1 to CPT 71010. Regardless of the sequence in which the x-rays were acquired, because these were performed at separate encounters on the same DOS, code 71020 is column 1 to column 2 code 71010 and the one-view chest x-ray would need to be modified to pass CCI edits.

Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at [email protected], or visit Panacea Healthcare Solutions at

The comments and observations expressed herein are those of the author and do not necessarily reflect the opinions of

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