Coding Corner: Modifier 59 (2023)

May 01, 2018
Area(s) of Interest: Practice Management


CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

(Video) Sam's Chiropractic Corner- Modifier 59

Modifier 59 Distinct procedural service is an “unbundling modifier.” When properly applied, it allows you to separately report—and to be reimbursed for—two or more procedures that normally would not be billed or paid independently during the same provider/patient encounter. For example, per CPT Assistant (Jan. 2018):

Code 20680 [Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)] describes a unit of service that is typically reported only once, provided the original injury is located at only one anatomic site, regardless of the number of screws, plates, or rods inserted, or the number of incisions required for removal. The removal of a single implant system or construct, which may require multiple incisions (eg, intramedullary [IM] nail and several locking screws) is reported only once with code 20680.

Reporting code 20680 more than once is appropriate only when the hardware removal is performed for another fracture(s) in a different anatomical site(s) unrelated to the first fracture (eg, ankle hardware and wrist hardware). In these circumstances, modifier 59, Distinct Procedural Service, would be appended to subsequent uses of the implant removal code.

(Video) Modifier 59 Spotlight

CPT® and CCI Conditions to Append Modifier 59
As outlined in the CPT® codebook, the general conditions under which you might append modifier 59 include situations where two or more CPT® codes, not normally reported together, are performed at a:


  • Different session

  • Different procedure or surgery

  • Different site or organ system: This condition “does not include treatment of contiguous structures of the same organ,” according to national Correct Coding Initiative (CCI) Chapter 1 guidelines, which apply to all Medicare payers. “For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.”

  • Separate incision/excision

  • Separate lesion or separate injury: Chapter 1 CCI guidelines clarify, “Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.”

Guidelines provide examples of proper use
Modifier 59 is necessary only if you wish to report/bill two services that normally are bundled. For Medicare and any payer that follows Centers for Medicare & Medicaid Services (CMS) guidelines, the surest way to confirm if two codes are bundled is to consult CCI edits. Any two codes designated within the CCI as “mutually exclusive,” or that are paired together as “column 1” and “column 2” codes, are bundled and not typically reported separately. Each CCI code pair edit includes a correct coding modifier indicator of “0” or “1.” A “0” indicator means that you may not unbundle the edit combination, under any circumstances. An indicator of “1” means that you may use a modifier (such as modifier 59) to override the edit, if the procedures are distinct from one another.

CCI Chapter 1 guidelines specify three conditions under which modifier 59 will always apply:


  1. When a diagnostic procedure precedes a surgical or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical or non-surgical therapeutic procedure is made, that diagnostic procedure may be considered to be a separate and distinct procedure as long as: (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical or non-surgical therapeutic procedure, it shall not be reported separately.

  2. When a diagnostic procedure follows a surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as: (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention; and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post- procedure service of the surgical procedure or non-surgical therapeutic procedure, it shall not be reported separately.

  3. There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two separate and distinct timed services are provided in separate and distinct time blocks, modifier 59 may be used to identify the services. The separate and distinct time blocks for the two services may be sequential to one another or split. When the two services are split, the time block for one service may be followed by a time block for the second service, followed by another time block for the first service. All Medicare rules for reporting timed services are applicable. For example, the total time is calculated for all related timed services performed. The number of reportable units of service is based on the total time, and these units of service are allocated between the HCPCS/CPT codes for the individual services performed. The physician is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate units of service. (e.g., A physician or therapist performs eight minutes of neuromuscular reeducation (CPT code 97112) and eight minutes of therapeutic exercises (CPT code 97110). Since the physician or therapist performed 16 minutes of related timed services, only one unit of service may be reported for one, not each, of these codes.)

When appending modifier 59 to break a CCI edit, you should always append the modifier to the secondary (“column 2”) code. The CCI guidelines provide two examples to illustrate proper application of modifier 59:

(Video) Modifier 59 and National Correct Coding Initiative (NCCI)

Example #1: The column one/column two code edit with column one CPT code 38221 (Diagnostic bone marrow biopsy) and column two CPT code 38220 (Diagnostic bone marrow, aspiration) includes two distinct procedures when performed at separate anatomic sites (e.g., contralateral iliac bones) or separate patient encounters. In these circumstances, it would be acceptable to use modifier 59. However, if both 38221 and 38220 are performed on the same iliac bone at the same patient encounter which is the usual practice, modifier 59 shall NOT be used. Although CMS does not allow separate payment for CPT code 38220 with CPT code 38221 when bone marrow aspiration and biopsy are performed on the same iliac bone at a single patient encounter, a physician may report CPT code 38222 (Diagnostic bone marrow; biopsy(ies) and aspiration(s)).

Example #2: The procedure to procedure edit with column one CPT code 11055 (Paring or cutting of benign hyperkeratotic lesion ...) and column two CPT code 11720 (Debridement of nail(s) by any method; 1 to 5) may be bypassed with modifier 59 only if the paring/cutting of a benign hyperkeratotic lesion is performed on a different digit (e.g., toe) than one that has nail debridement. Modifier 59 shall not be used to bypass the edit if the two procedures are performed on the same digit.

Modifier 59 should be your last resort
You should append modifier 59 only if no other modifier applies. CCI guidelines confirms this: “Modifier 59 shall only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.”

For example, guidelines in the microbiology subsection of the CPT® codebook illustrate when modifier 91 Repeat clinical diagnostic laboratory test is preferable to modifier 59 when reporting repeat laboratory tests performed on the same day:

(Video) Physical Therapy 59 Modifier Update 2020

Presumptive identification of microorganisms is defined as identification by colony morphology, growth on selective media, Gram stains, or up to three tests (eg, catalase, oxidase, indole, urease). Definitive identification of microorganisms is defined as an identification to the genus or species level that requires additional tests (eg, biochemical panels, slide cultures). If additional studies involve molecular probes, chromatography, or immunologic techniques, these should be separately coded in addition to definitive identification codes (87140-87158). For multiple specimens/sites use modifier -59. For repeat laboratory tests performed on the same day, use modifier -91.

Finally, you should never append modifier 59 to evaluation and management (E/M) service codes (e.g., outpatient office visits 99201-99215). For example, to report an E/M service that results in the decision to perform a major surgical procedure (i.e., a procedure with a 90-day global period), and that E/M service occurs on either the day of, or the day before, a major surgical procedure, you should report the appropriate E/M code with modifier 57 Decision for surgery appended. For a separate E/M service that determines the need for a minor procedure (i.e., any procedure with a global period of less than 90 days), you should turn to modifier 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure.

X{EPSU} modifiers provide an alternative to 59
Effective for dates of service beginning January 1, 2015, CMS released four new modifiers for Medicare claims, to be appended in lieu of 59 Distinct procedural service under defined circumstances. CMS describes the new modifiers, announced in CMS Transmittal 1422, Change Request 8863, as “subsets of distinct procedural services (-59 modifier),” to include:


  • XE – Separate Encounter – Used to describe services that are separate because they take place during separate encounters;

  • XS – Separate Structure – Used to describe services that are separate because they are performed on different anatomic organs, structures or sites;

  • XP – Separate Practitioner – Used to describe services that are distinct because they are performed by different practitioners; and

  • XU – Unusual Non-Overlapping Service – Used to describe services that are distinct because they do not overlap the usual components of the main service.

Currently, use of the X{EPSU} modifiers is not mandatory; however, CMS has encouraged immediate adoption of the X{EPSU} modifiers by all Medicare payors, stating, “contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.” As such, not only should medical providers prepare for the new modifiers, they should also expect even greater scrutiny of any modifier 59 claims, as well.

(Video) 59 modifier made easy

FAQs

Where do you put modifier 59? ›

For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury.

What situation is modifier 59 most commonly used for? ›

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. It is the most reported modifier that affects National Correct Coding Initiative (NCCI) processing.

Does modifier 59 go on column1 or column 2 code? ›

Modifier 59 should never be used to simply bypass an edit when the above criteria have not been met. Modifier 59 is appended to the Column 2 code in the NCCI table. Modifier 59 is not an evaluation and management modifier.

Do you need a modifier 59 on an add on code? ›

Normally these procedures are considered inclusive. If the 59 modifier is appended to either code, they will both be allowed on the claim separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15 minute intervals.

Which modifier goes first 59 or TC? ›

If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier. If you have two payment modifiers, for example 51 and 59, enter 59 first and 51 second.

When to use 59 or 51 modifier? ›

While modifier 51 and 59 both apply to additional procedures performed on the same date of service as the primary procedure, modifier 51 differs from modifier 59 in that it applies to procedures that may be more commonly expected to be performed during the same session.

How does modifier 59 affect reimbursement? ›

Modifier 59 allows you to unbundle — separately report and get paid for — two or more procedures occurring during the same encounter by the same physician that would not normally be paid independently. Use modifier 59 correctly, and you'll collect every penny of reimbursement for the work you do.

Can modifier RT and 59 be used together? ›

different shoulders, modifiers RT and LT should be used, not modifier 59. LT and RT have not effect on the actual processing of the claim for payment, because they are informational.

What is the difference between modifier 59 and 91? ›

Definition of modifier 91 & 59

Modifier -91 is not to be used for procedures repeated to verify results or due to equipment failure or specimen inadequacy. While 59 is used for differentiating two procedures while cannot be billed together on same day.

Does the 59 modifier go on 97140 and 97530? ›

When using the 59 modifier, you are indicating to the insurance company that each service was medically necessary and performed independently of the other. One typical example of when to use this modifier is if you bill for manual therapy (97140) and therapeutic activities (97530), in the same session.

What are Column 1 and Column 2 codes? ›

Column 1 indicates the payable code. Column 2 contains the code that is not payable with this particular Column 1 code, unless a modifier is permitted and submitted. The third column indicates if the edit was in existence prior to 1996.

Can modifier 59 be used with an unlisted CPT code? ›

Is it appropriate to append a modifier to an unlisted CPT code? The answer is no. Modifiers exist solely to amend a specific and established definition of a procedure or service. By their very nature, unlisted CPT codes are undefined; amending them with a modifier will not make them any more specific.

Is modifier 59 an anatomical modifier? ›

For CCI, the primary purpose of CPT modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationship of the procedure codes.

Can 96372 be billed with modifier 59? ›

When a patient receives two or three intramuscular or subcutaneous injections, CPT code 96372 should be reported for each injection performed (either IM or SubQ). Modifier 59, Distinct Procedural Service, would be appended to the second and any subsequent injection codes listed on the claim form.

What is difference between Xs and 59 modifier? ›

The use of modifier 59 or XS indicates the service is a separate and distinct service from manipulation; however, the use of modifier XS would technically be more correct or accurate than 59.

When should modifier TC be used? ›

Modifier TC is used when only the technical component (TC) of a procedure is being billed when certain services combine both the professional and technical portions in one procedure code. Use modifier TC when the physician performs the test but does not do the interpretation.

What does modifier TC stand for? ›

Modifier TC is defined as “Technical Component” and should be appended to a procedure code when the provider rendered only the technical component of the service.

Which modifier should go first? ›

In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursement process first.

Is 59 modifier still valid? ›

Modifier 59 is not going away and will continue to be a valid modifier, according to Medicare. However, modifier 59 should NOT be used when a more appropriate modifier, like a XE, XP, XS or XU modifier, is available. Certain codes that are prone to incorrect billing may also require one of the new modifiers.

What is the 51 modifier used for? ›

Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries performed on the same day, during the same surgical session. Diagnostic Imaging Services subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider.

What modifier goes first 50 or 51? ›

You should list the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and subsequent procedures.

What is the 59 denial code? ›

Reason Code 59: Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.

What is the difference between modifier 51 and modifier 59? ›

Modifier 51 is not appended to add-on codes like CPT code 64462. Modifier 59 refers to Distinct Procedural Service which indicates that a procedure is separate and distinct from another procedure provided on the same date of service.

Are modifiers 25 and 59 interchangeable? ›

Recently, ACP has received several member inquiries regarding the use of CPT modifiers 59 and 25 in conjunction with evaluation and management (E/M) codes. The two modifiers are very similar, but not interchangeable.

What is modifier RT used for? ›

Right side (used to identify procedures performed on the right side of the body).

Can you bill modifier 59 and 51 together? ›

Never use both modifier 51 and 59 on a single procedure code. If there is a second location procedure (such as a HCPCS code for right or left), use the CPT® modifier first.

What is GP 59 modifier? ›

Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances.

What modifiers can be used with 97140? ›

The 97140 CPT code is appended with the modifier -59 or the appropriate -X modifier.

What CPT codes Cannot be billed together? ›

The following CPT® codes may not be reported with 99439 in the same calendar month: 90951-90970, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380, 99487, 99489, 99491, 99605, 99606, 99607.

Can CPT codes 97140 and 97530 be billed together? ›

Code 97140 is mutually exclusive with code 97530 and cannot be billed using any modifier.

What is a column 2 code edit per NCCI? ›

Column 2 contains the code that is not payable with this particular Column 1 code unless a modifier is permitted and submitted. This third column indicates if the edit was in existence prior to 1996. The fourth column indicates the effective date of the edit (year, month, date).

What are Category 2 codes? ›

CPT Category II Codes are supplemental tracking codes used for performance measurement and data collection related to quality and performance measurement, including Healthcare Effectiveness Data and Information Set (HEDIS®).

What are the two common types of codes? ›

Algebraic coding theory is basically divided into two major types of codes:
  • Linear block codes.
  • Convolutional codes.

Can modifier 59 be used for ultrasound? ›

Modifier 59 is recognized as appropriate when billed with obstetrical ultrasounds, CPT® procedures codes 76813 through 76828.

What is the difference between modifier 59 and 79? ›

Modifiers 59 and 79 can be confused as well. Both can refer to unrelated procedures by the same physician. However, 79 focuses on the post-operative period, while 59 centers more specifically around same-day or same-session procedures.

What is the difference between modifier 59 and 76? ›

Modifier 59 refers to procedures or services completed on the same day that is because of special circumstances and are not normally performed together. Modifier 76 refers specifically to the same procedure performed multiple times by the same medical professional after the initial service.

What is a anatomical modifier? ›

Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims. Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.

Does CPT code 96372 require a modifier? ›

The 96372 CPT code is to be billed for each injection performed on a patient. Modifier 59 should be used when the injection is a separate service from other treatments. Requirements for Reimbursement: Direct Physician Supervision – must be done under the direct supervision of an MD.

Can CPT code 96372 be billed twice? ›

The IM or SQ injection can be billed more than once or twice. If the drug is prepared and drawn up into two separate syringes and it is then administered in two individual injections in two distinct anatomic sites, you can bill two units of code 96372 (billing second unit with modifier 76).

Can 96372 and 90471 be billed together? ›

You can bill both admin codes.

What does modifier Xs stand for? ›

Modifier XS Separate structure – A service that is distinct because it was performed on a separate organ/structure.

Can modifier 59 be used with 99213? ›

If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.

When should RT modifier be used? ›

The right (RT) and left (LT) modifiers must be used when billing two of same item or accessory on the same date of service and the items are being used bilaterally.

Videos

1. Proper Usage of Modifier 59
(AWA Support)
2. NCCI Edits - Guide to the CMS National Correct Coding Initiative
(Contempo Coding)
3. VLOGMAS DAY 10: MODIFIER 58 | STAGED OR RELATED PROCEDURE | MEDICAL CODING WITH BLEU
(Medical Coding with Bleu)
4. Perspective | Critical Role | Campaign 2, Episode 59
(Critical Role)
5. The Feywild | Critical Role: VOX MACHINA | Episode 59
(Geek & Sundry)
6. Sam's Chiropractic Corner- CMT 98940, 98941, 98942, & 98943 Ratio
(HJ Ross Company)
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