New Medicare Modifiers XE, XP, XS, XU: Examples of When to Bill Each One

The four new Medicare modifiers for 2022 are:

• XE: Separate encounter, a service that is distinct because it occurred during a separate encounter.
• XP: Separate practitioner, a service that is distinct because it was performed by a different practitioner.
• XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure.
• XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.

These new modifiers provide more opportunities for providers to bill accurately for specific scenarios involving separate or distinct services. However, it is essential to understand the exact meaning of each modifier and when it is appropriate to use. Misuse of modifiers can lead to claim denials or allegations of fraud.

Below are detailed explanations and examples to illustrate appropriate uses of modifiers XE, XP, XS, and XU.

This modifier should be used when:

• Services provided are unrelated or independent from other services provided on the same date.
• Services involve distinct staff at separate times.
• Services occur in entirely separate locations within the facility.

Modifier XE provides a way to denote that a specific service was its own separate encounter even though other services occurred on the same date.

Some examples include:

• A patient receives a flu shot from a nurse at a doctor’s office in the morning. Later that afternoon, the patient has a separate visit with the doctor for back pain. The visit can be billed with an XE modifier to show it was a distinct encounter from the earlier flu shot.
• A patient has a wound check in the morning with a nurse in the clinic room. The patient returns later that day and has an appointment with a mental health counselor in a different office room. The counselor would append XE to their service to indicate it was separate.
• A physician performs a surgery in the main operating room in the morning. In the afternoon, the physician evaluates the patient during rounds in their inpatient room. The evaluation during rounds would be billed with an XE modifier.
• A patient undergoes physical therapy in the rehabilitation gym in the morning. Later, they see a psychologist in a separate office suite for a therapy session. The psychologist would use XE to show their service was an unrelated encounter.

The key point is that modifier XE should only be used when services are completely separate or independent from others furnished on the same date.

XP is appropriate to use when:

• Services are provided by different clinicians who are not in the same group practice.
• Two practitioners in the same group provide unrelated services.
• Different specialists within a group provide separate services.

Reporting modifier XP helps identify that a particular service was distinctly performed by a separate practitioner.

Examples include:

• An ophthalmologist in one physician group exams a patient’s eyes in the morning. A dermatologist in a different group removes a skin lesion on the patient’s arm later that day. The dermatologist would use XP to indicate their service was done by a separate practitioner.
• A family medicine doctor performs an annual physical exam on a patient in the morning. The patient sees a separate psychologist from the same family practice that afternoon for depression. The psychologist should append XP to their service to show it was rendered by a different practitioner.
• An orthopedic surgeon in a multispecialty group sets a patient’s fractured arm in the morning. A neurologist in the same practice evaluates the patient for headaches later that day. The neurologist would bill using XP to identify them as a separate practitioner.
• A cardiologist inserts a pacemaker in a surgery center in the morning. An anesthesiologist from the same surgery center provides sedation for the procedure. The anesthesiologist would still use modifier XP to indicate they are a different practitioner than the cardiologist.

The critical factor is that XP should be used when services are furnished by different individuals. The practitioners can be in separate groups or the same group if they are different specialty providers.

This modifier is appropriate to report when:

• Services are performed on separate organs or structures of the body.
• Services provided address different diagnosis codes impacting unrelated body areas.
• Testing or procedures evaluate distinct anatomical sites.

Identifying services as occurring on separate body structures helps communicate important clinical differences between services delivered.

Examples include:

• A dermatologist performs a mole removal on a patient’s back in the morning. The patient sees a podiatrist later that day for a bunionectomy on their foot. The podiatrist would append XS to show their service addressed a separate anatomical site.
• An orthopedic surgeon sets a fracture of the patient’s right wrist earlier in the day. The patient follows up with their primary care doctor later for a sinus infection exam. The primary care physician would use XS to identify the sinus exam was a separate anatomical structure.
• A general surgeon repairs a hernia in the morning. The patient sees a gynecologist in the afternoon for evaluation of pelvic pain. The gynecologist documents modifier XS to indicate their service focused on a different body system.
• A gastroenterologist performs a colonoscopy on a patient in the morning. A cardiologist sees the patient later that day for evaluation of chest pain. The cardiologist reports XS to denote their cardiac assessment addressed a separate organ system than the GI procedure.

The key purpose of modifier XS is to distinguish services provided to unrelated anatomical sites or body systems. This can include separate organs, limbs, areas of the skin, or unrelated structures.

This modifier can be used when:

• An additional service is provided that does not normally accompany the primary procedure.
• There is a component performed that exceeds the usual approach for the overall service billed.
• Extra items distinct from the typical service are included.

Identifying an unusual non-overlapping service with modifier XU communicates that extra distinct care was delivered beyond the main service.

Examples include:

• A surgeon performs a laparoscopic gallbladder removal on a patient. During the same operative session, the surgeon examines and lyses extensive adhesions that are unexpected. The lysis of adhesions could be billed with an XU modifier to indicate it was an unusual non-overlapping service during the cholecystectomy.
• A neurologist provides a basic EEG test for a patient with seizures. Upon viewing the tracings, the neurologist notes significant abnormalities and decides to order stat MRI imaging. The extra MRI interpretive service would warrant an XU modifier as it exceeds the usual EEG testing components.
• An orthopedist sets a complex elbow fracture requiring an external fixator device. The basic procedure normally entails application of pins and bars. However, the patient’s extensive swelling and ligament damage necessitates extra soft tissue repair at the time of surgery. The soft tissue repair would justify reporting modifier XU since it does not overlap the typical procedure.
• A plastic surgeon performs a standard nasal tip rhinoplasty. However, upon examining the patient’s interior nasal septum intraoperatively, a septoplasty is also required to correct unforeseen deformities. The septoplasty would be billed with an XU modifier to indicate it was an additional non-overlapping service.

Modifier XU helps communicate that extra services were provided above and beyond the main or typical procedure performed. This identifies added value to care delivered.

To summarize, the four new Medicare modifiers for 2022 are:

• XE: Separate encounter
• XP: Separate practitioner
• XS: Separate structure
• XU: Unusual non-overlapping service

These modifiers provide specificity when services are distinct or exceed the usual components of care:

• XE denotes services delivered during a wholly separate patient encounter on the same date.
• XP indicates services performed by different clinicians, whether in separate practices or different specialties within the same group.
• XS identifies procedures addressing unrelated anatomical sites or body systems.
• XU designates atypical additional services that do not normally overlap the main service provided.

Using modifiers appropriately is key to accurate coding and billing.

Some final best practices include:

• Do not use modifiers just to bypass edits if services are not truly separate.
• Append modifiers to the correct CPT code for the distinct service they describe.
• Documentation must support the specific rationale for using modifiers.
• Educate clinicians on when it’s appropriate to use new modifiers XE, XP, XS, XU.
• Monitor claims with these modifiers to ensure compliance.
• Be prepared to justify use of modifiers if requested on audit.