How do payers compensate different healthcare providers involved in the same patient’s care? They require billing entities to use modifiers! Did you know that there is always a modifier for a specific situation? For the longest time, modifier 59 was the only choice for indicating distinct services. However, it was often misapplied to bypass bundling edits, leading to incorrect payments and more scrutiny.
So, how did CMS overcome this problem? By introducing more specific codes, collectively known as the X{EPSU} modifiers. Each code provides specific information regarding why a service is distinct. Today, let’s discuss Modifier XP — one of the alternatives to Modifier 59 that specifies a separate practitioner performing the service.
XP Modifier – Description
As mentioned in the introduction, modifier XP is one of the more specific replacements for modifier 59. But what does it actually mean? This two-character HCPCS code in medical billing indicates that a non-E/M procedure or service is distinct because it is performed by a different practitioner.
Before moving on to other details, let’s address an important question: Who qualifies as a separate practitioner when using modifier XP? A different practitioner is simply a different healthcare provider from the one who performed other services on the same day. This provider is usually part of the same group practice and specialty.
In simpler terms, modifier XP indicates that the involvement of a different clinician distinguishes the performed service from others provided to the same patient on the same date.
Scenarios Where Modifier XP is Applicable
Multiple doctors in the same group perform multiple procedures within the same day. Modifiers are the powerful codes that ensure each provider receives fair compensation for their services.
Want to use modifier XP accurately? Look at the following scenarios to understand XP’s proper application.
Colorectal Cancer Surgery with Lymphadenectomy by a different Surgeon
Let’s start with a simple example! Suppose a 70-year-old man with colorectal cancer is admitted to the hospital for treatment. The surgeon performs a partial colectomy (CPT code 44147) to remove the diseased portion of the patient’s colon.
Another surgeon in the same practice performs an add-on procedure, removing the abdominal lymph nodes (CPT code 38747) affected by colon cancer to reduce bloating and swelling. Although CPT code 38747 is usually bundled with CPT code 44147, the billing team bills it separately with modifier XP due to the involvement of a different practitioner.
Abdominal and Pelvic Ultrasound by Different Radiologists
Let’s consider another example! Assume a 23-year-old woman with severe abdominal pain and irregular periods is referred by a doctor for several tests. She visits the radiology department, where a radiologist performs an abdominal ultrasound (CPT code 76700) to determine the cause of her discomfort.
Later in the day, a different radiologist performs a pelvic ultrasound (CPT code 76856) to evaluate her menstrual problems. Since both tests are performed by different practitioners on the same patient and same date, the billing team applies modifier XP to the second procedural code.
Joint Aspiration by Different Orthopedic Specialists
Suppose a 25-year-old athlete visits an orthopedic clinic after a fall. He has excessive swelling and redness in his right shoulder. The doctor evaluates the patient, diagnoses bursitis, and inserts a needle into his shoulder joint (CPT code 20611) to remove the fluid using ultrasound guidance.
Later in the day, the patient complains of knee pain. Another orthopedic specialist performs a knee joint aspiration (CPT code 20610) to remove the fluid and relieve the pain without ultrasound guidance. Since a different doctor performs the second procedure, the billing specialists apply modifier XP to CPT code 20610.
Modifier XP – Billing & Documentation Guidelines
The Centers for Medicare and Medicaid Services (CMS) have a proper guide on how to use X{EPSU} modifiers. But we understand that you may not have the time to check every detail about each code. So, if you want to reduce claim denials, follow our billing and documentation guidelines for using modifier XP.
Verify if the Services Are Performed by a Separate Practitioner
The first and most important requirement of using this code is that a separate practitioner must be involved on the same date of service. Simply put, the distinct services must be performed by a different provider than the one who performed other procedures or services earlier in the day.
Therefore, carefully verify the involvement of different practitioners before using modifier XP. Use a different code if the service is distinct due to another reason.
Apply Modifier XP to Non-E/M Services Only
Another important rule is that you can only apply modifier XP to non-E/M services. Hence, avoid using it with evaluation and management codes, CPT codes 99202 to 99499, to receive fair reimbursements.
Check the NCCI Procedure-to-Procedure (PTP) Edits
Avoid using modifier XP to bypass NCCI edits. Make it a habit to check the Correct Coding Modifier Indicator (CCMI) of your coding pair before applying this two-character code. If the CCMI value is “1”, you can report your codes together with the XP modifier.
Keep one thing in mind! Only add this code to the secondary or subsequent procedures that qualify as distinct. Apply it to the column 2 procedural code in NCCI edits.
Comply with Medicare & Other Payer Policies
Insurance companies may have different policies. Therefore, our usual advice is to check payer-specific rules to confirm modifier XP’s requirements.
Maintain Complete Documentation
So, what are the documentation requirements for using modifier XP? Your documents should:
- Help payers distinguish separate practitioners
- Support the distinct nature of procedures
- Include procedural details
Therefore, your records should include the following information:
- Name and credentials of each provider
- Date and time of each procedure
- Reason for performing both services on the same day
- Test results, diagnoses, clinical notes, or anything that can justify the medical necessity
Avoid Basic Mistakes
Modifier XP is inappropriate in certain situations. Specifically, avoid using it:
- With weekly radiation therapy management codes, such as 77427.
- With duplicate procedures (when the exact same procedures are performed on the same day)
Summary
In short, as one of the alternatives to modifier 59, modifier XP is used for billing certain codes at high risk of claim denials due to incorrect billing. This HCPCS code highlights a specific reason for a service to be considered distinct—the involvement of a separate practitioner. In simple terms? You can use this code with secondary procedures performed on the same day by a different physician than the one who performed prior services. We have covered all the details and requirements of modifier XP so you can use it accurately and receive fair compensation for all healthcare providers.
