Effective April 12, 2019, AmeriHealth will deny single line claims that are billed with Modifier 59. The reason for this change is to align our Modifier 59 claim payment policy with our position prohibiting split-billing of claims.

Background

Providers have been permitted to submit claims with modifiers XE, XS, XP, and XU since January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where Modifier 59 was previously reported. The AmeriHealth claim payment policy regarding modifiers XE, XS, XP, XU, and 59 specifically states that Modifier 59 should only be reported when it is the most accurate modifier that is available to describe the circumstances of the procedure or service, and modifiers XE, XS, XP, or XU do not meet the criteria.

Modifier 59 is used for a “Distinct Procedural Service.” In some circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.

When a single service is billed with Modifier 59 (single-line claim), it is an indication that either:

• one of the more specific modifiers such as XE or XP would meet the criteria, and therefore Modifier 59 should not have been used; or
• the claim is being split-billed from another service rendered on the same day by the same provider.

Split-billing is prohibited under the Hospitalization and Outpatient Services section of the Provider Manual for Participating Professional Providers.

To help ensure accuracy of claim submission and compliance with the AmeriHealth prohibition against split-billing, we will no longer allow a Modifier 59 to be billed on a single line claim effective April 12, 2019. If a provider submits a single line claim with Modifier 59 on or after April 12, 2019, then it will be denied via a provider explanation of benefits.

Policy

For more information, refer to the AmeriHealth Claim Payment Policy #03.00.08d: Modifiers XE, XS, XP, XU, 59.

To view this policy, visit our Medical Policy Portal, select Accept and Go to Medical Policy Online, then select Commercial Policies, and then type the policy name or number in the Search field.

For more information

For instructions on how to properly apply the modifiers and further reading about split-billing, you can reference the Hospitalization and Outpatient Services section of the Provider Manual for Participating Professional Providers.

If you have additional questions after reading this communication, please email ahclaimeditquestions@amerihealth.com.