Are you tired of receiving denials on medical claims with modifier 59? If your answer is affirmative, then it is time to conduct an internal audit because you may be inappropriately appending every other claim with the modifier 59 in hopes of bypassing the bundling issues.
This revelation may sound harsh, but it can be a reality since there are more specific modifiers available. These modifiers help you indicate to the payer why you believe a particular procedure is eligible for a separate reimbursement from other services rendered on the same day and what makes them distinct.
This guide will discuss everything you need to know about one such modifier, i.e., the XU modifier. Thus, if you want to streamline your medical coding and billing workflow, read this guide till the end.
XU Modifier – Description
This modifier is from the X{EPSU} modifier set that the Centers for Medicare and Medicaid (CMS) introduced in 2015. The X{EPSU} modifiers are a subset of modifier 59, which identifies that a procedure or service is distinct and separately payable from other procedures or services performed on the same day for the same patient.
The main reason behind introducing the X{EPSU} modifiers is to enable better coding specificity while preventing healthcare providers from overusing/misusing the modifier 59.
Now, coming back to the XU modifier! This modifier stands for ‘Unusual Non-Overlapping Service’. Simply put, this modifier indicates that a procedure is distinct and eligible for a separate reimbursement because its usual components do not overlap with that of the primary service rendered on the same day to the same patient.
Scenarios Where Modifier XU is Applicable
Let’s review some scenarios where the XU modifier can be applied to understand its scope of usage:
Testicular Pain Ultrasound
Assume a scenario where a patient underwent a cystoscopy for hematuria evaluation. During the procedure, the urologist discovers and biopsies a suspicious bladder lesion.
However, the patient complained of acute testicular pain later in the same encounter, so the urologist conducted a testicle ultrasound. Since the testicular ultrasound is an unusual, non-overlapping procedure compared to bladder biopsy and cystoscopy, the XU modifier will be applied to the ultrasound CPT code to ensure rightful reimbursements.
Corneal Abrasion Debridement
What happens when a patient visits an ophthalmologist for a routine cataract evaluation, (including a standard eye exam and biometry) but the provider finds an unexpected abrasion unrelated to the cataract? The ophthalmologist performs a corneal debridement procedure.
Thus, the XU modifier will be appended to the corneal debridement procedure because it is unusual and non-overlapping compared to the standard cataract evaluation. Using this modifier will help you ensure timely payment and avoid bundling issues.
Ovarian Cystectomy Discovery
Consider a patient who comes for a scheduled laparoscopic appendectomy, but during the surgical procedure, an unrelated and acute ovarian cyst rupture is discovered. Thus, the surgeon performs a laparoscopic ovarian cystectomy.
However, this second procedure was unusual and non-overlapping compared to the laparoscopic appendectomy. Therefore, the surgeon should append the XU modifier to the laparoscopic ovarian cystectomy CPT code to avoid bundling errors.
Modifier XU – Billing & Documentation Guidelines
The following are the XU modifier billing and documentation requirements:
Understanding the NCCI Edits
You should use the XU modifier when, under the National Correct Coding Initiative (NCCI) edit, the multiple rendered procedures (two or more) on the same service date would have been bundled together. Thus, if one of the procedures is distinct, apply this modifier to avoid bundling errors.
Unusual, Non-Overlapping Components
Only append the XU modifier when the rendered procedure is distinct, unusual, and does not have any overlapping components compared to the primary (main) procedure. It will ensure you receive your rightful reimbursements.
Provide Comprehensive Documentation
When you submit a medical claim with the modifier XU, you should ensure documentation completeness and accuracy. Thus, your documentation should include the rendered services, justify the medical necessity of each performed procedure, and what makes the unusual procedure distinct from the primary service.
Other necessary details include explaining why the unusual service does not overlap with the main procedure’s components and the time and sequence of the rendered services.
Common Mistakes Related to the Use of the XU Modifier
The inappropriate use of the XU modifier may lead to serious repercussions, from claim denials to audits, hefty financial penalties, and criminal lawsuits. Thus, understanding common mistakes while using this modifier will help you ensure you do not follow suit.
- Confusing services as unusual and non-overlapping based on their different descriptors.
- Using it for evaluation and management (E/M) services.
- Appending the XU modifier when another X{EPSU} modifier most specifically describes why a procedure is distinct and eligible for separate reimbursement.
- Applying this modifier to procedures typically performed together and bundled under the NCCI edits.
- Overusing or misusing the XU modifier, aiming to bypass the NCCI edits or receive unfair higher reimbursements.
- Failure to justify the appropriateness of appending this modifier through adequate documentation.
Best Practices to Avoid Inappropriate Use of the XU Modifier
Discussed below are some industry best practices to help you ensure the appropriate use of the XU modifier:
- Review the clinician notes and documentation related to the rendered procedures thoroughly before applying this modifier.
- Append the XU modifier only when it is the most appropriate modifier that defines the distinct and separately payable procedures among the X{EPSU} modifiers.
- Conduct regular audits and review the status of previously submitted claims with this modifier. In case you have received denials on claims submitted with the XU modifier in the past, you should review your coding and billing workflow to identify potential gaps.
- Invest in ongoing training of your billing and coding staff on the proper use of modifiers to prevent future denials, ensure a steady cash flow, and avoid audits.
- Stay current on any changes in the CMS guidelines and NCCI edits regarding the X{EPSU} modifiers’ accurate usage.
- Keep your documentation accurate and up-to-date. Besides, be prepared to facilitate additional information as the insurance payer may require it to process your medical claim with the XU modifier.
Summary
We have covered all aspects of the XU modifier and hope it will help you enhance your overall medical coding and billing game. But before we wrap up, let’s quickly revisit what we learned! We explained that CMS introduced the X{EPSU} modifiers in 2015 to enhance coding specificity, and the modifier XU is used to indicate an unusual procedure whose usual components do not overlap with the components of the primary service rendered on the same day.
We also shared some examples to help you understand its application. Moreover, we discussed the modifier XU’s billing and documentation guidelines, common mistakes related to its usage, and best practices to ensure timely and fair reimbursements.
