How do insurers manage the reimbursement of different providers who participate in a patient’s care? The answer is through the use of modifiers: codes that expand upon additional information attached to the service.
For over a decade, the most commonly abused modifier was marker 59. Although it served as an indicator for distinct services, it was frequently applied incorrectly and resulted in improper payments and claim denials. To deal with this concern, the Centers for Medicare & Medicaid Services (CMS) showed compassion by offering more precise alternatives known as X{EPSU} modifiers. These modifiers explain the reason for the service’s uniqueness, hence lowering the claim processing errors.
Today, we’ll talk about modifier XP, which is now the replacement for modifier 59 and explains that a service is performed by a different healthcare provider. Let’s discuss it as follows.
Scope of Modifier XP
In medical billing, the modifier XP is a two-character HCPCS code that indicates a non-E/M procedure or service is separate due to a different practitioner. But what does that mean in practice?
A separate practitioner is a healthcare provider within the same group practice or specialty who performed a clinical service on the same day as another provider. In basic terms, Modifier XP marks a service as distinguishable because a different clinician performed it.
Let us look at real-life situations where Modifier XP is relevant.
When to Use Modifier XP
Modifiers ensure that all the providers who participated in a patient’s care get paid appropriately. But in which instances should one apply XP? Below are some frequent examples.
Scenario 1: Abdominal and pelvic ultrasounds by different radiologists
A 23-year-old woman with severe abdominal pain goes to the radiology department for an abdominal ultrasound (CPT 76700). Subsequently, a different radiologist performs a pelvic ultrasound (CPT 76856) later during the day to assess irregular menstrual periods.
As there are two different radiologists who performed these services, Modifier XP is applied to the second service.
Scenario 2: Surgical Procedure for Colorectal Cancer and Lymphadenectomy
A man aged 70 years has a colon cancer partial colectomy for a cancerous portion of his colon. A second surgeon in the same practice does a lymphadenectomy and removes the associated lymph nodes.
These services are often performed together. Because of this, the billing department uses Modifier XP to CPT 38747. XP is used to show that the lymphadenectomy was performed by a different practitioner.
Scenario 3: Joint aspirations by different orthopedic specialists
After falling, a 25-year-old athlete presents to the orthopedic clinic. One of the specialists performs a joint aspiration of the shoulder (CPT 20611) to relieve the swelling, and later another orthopedic physician does a knee joint aspiration (CPT 20610) for another injury.
Use XP Modifier for Non-E/M Services Exclusively
XP modifier is not applicable for evaluation and management (E/M) services – CPT codes 99202 through 99499. It is only relevant for procedures and non E/M services.
Review NCCI PTP Edits
Modifier XP should never be used to inappropriately bypass National Correct Coding Initiative (NCCI) edits. Modification Checkstep Correct Code Modifier Indicator (CCMI) always comes first:
Use modifier XP if “1” was returned. A distinct service has already been rendered.
If “0” is returned, there are no un-bundlable services even with a modifier.
Modifier XP is issued for the secondary process only, not the primary.
Follow Payer Specific Policies
Policy differences exist among the payers for Modifier XP. Always double check payer policies for compliance to bypass denial risks.
Keep Complete Documentation
Success for reimbursement is achieved through detailed documentation. The provided records should include:
- Each provider’s name and credential
- The date and time of each service performed
- The rationale for performing both services on a single day
- Clinical notes, tests results and diagnoses justifying the medical necessity
Mistakes You Should Not Make
Even though Modifier XP has its benefits, it could also prove rather useless at times. Common mistakes include the follwoing:
Using Modifier XP for Weekly Radiation Therapy Management Codes
- Example: CPT 77427 (radiation therapy management)
Applying Modifier XP to Duplicate Procedures
- If the exact same procedure is done in a single day, it cannot be applied with modifier XP.
Conclusion
In medicine, when billing certain services rendered on the same day by different providers, it is often told that modifier XP should be applied. In contrast to frequently misapplied Modifier 59, which encountered gross abuse, XP offers sharp logic for dividing services.
Healthcare providers who adhere to policies and procedures regarding billing and documentation are bound to get XP, but not get their claims rejected. Are you having issues with proper medical coding? Reach out to us at XyberMed.