Taking the fear out of modifier 59

 Modifier 59 was established to demonstrate that multiple yet distinct services were provided to a patient on the same date of service by the same provider.  Because distinct procedures or services rendered on the same day by the same physician cannot be easily identified and therefore properly adjudicated by simply listing the CPT procedure codes, modifier 59 assists the third-party payer or Medicare carrier in applying the appropriate reimbursement.  If the modifier is not used in these circumstances, a denial of services may result with an explanation of benefits stating, for instance for Medicare claims, "Medicare does not pay for this service because it is part of another service that was performed at the same time." 

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.  This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not usually encountered or performed on the same day by the same physician.  However, this is the modifier of last resort.  If no other modifier is available or appropriate, and the use of modifier 59 best explains the circumstances, then you should use it. 

USING THE MODIFIER CORRECTLY
Use modifier 59 when billing a combination of codes that would normally not be billed together.  This modifier indicates that the ordinarily bundled code represents a service done at a different anatomical site or at a different session on the same date.  This may represent:

·         different session or patient encounter

·         different procedure or service/same day

·         different anatomical site or organ system (e.g., a skin graft and an allograft in different locations).

·         separate incision/excision

·         separate lesion (e.g., a biopsy of skin on the neck is performed at the same session as an incision of a 1.0 cm benign lesion of the back).

·         separate injury.

Use modifier 59 only on the procedure designated as the distinct procedural service.  The physician needs to document that a procedure or service was distinct or separate from other services performed on the same day.

Ensure that the medical record documentation is clear as to the separate and distinct procedure before appending the modifier 59 to a code.  This modifier allows the code to bypass edits; therefore, appropriate documentation must be present in the record.  Note:  Medicare uses the Correct Coding Initiative (CCI) screens when editing claims for possible unbundling.  Under CCI screens, specific codes have been identified that should not be billed together. 

When a recurrent hernia requires repair (herniorrhaphy, hernioplasty), bill the appropriate recurrent hernia code.  A code for incisional hernia repair is not to be billed in addition to the recurrent hernia repair unless a medically necessary incisional hernia repair is performed at a different site.  In this case, attach modifier 59 to the incisional hernia repair code.

INCORRECT USE OF THE MODIFIER

Appending modifier 59 to E/M codes.

Using the modifier as a replacement for modifiers 24, 25, 51, 78, or 79.

Using modifier 59 when another modifier best describes the distinct service.

Reporting modifier 59 with modifier 51 on the same CPT code.

CLINICAL EXAMPLES

Example #1:
An arch aortogram and bilateral selective common carotid angiograms are performed by femoral approach.  Radiological supervision and interpretation codes are 75650-26 and 75630-26.  Results came back with 70 percent stenosis of the right carotid and 95 percent stenosis of the left carotid.

The injection codes are 36216 and 36215-59.  The modifier 59 is used to indicate a different arterial family.

Example #2:
A patient presents for a diagnostic endoscopy that result in a decision to perform an open surgical procedure.  The diagnostic endoscopy would be reported using modifier 59 to indicate a distinct diagnostic service when performed at a separate session.

Example #3:
A patient presents with a possible aspiration of a foreign body (food) and a diagnostic bronchoscopy is performed indicating a lobar foreign body.  A decision is made to remove the foreign body by thoracotomy. 

The same-day open thoracotomy is reported in addition to the diagnostic bronchoscopy, which should be appended with the modifier 59.

Example #4:
A patient presented for the removal of 13 skin tags from his back.  At the same session, the physician noted two small lesions (not skin tags) on the patient's neck area.  Biopsies were taken of each lesion, as each appeared different in morphology.

CPT codes 11200, 11100-59, and 11101 are submitted.  It may also be advisable to append the 59 modifier onto the add-on code 11101 in order to show the payer the additional biopsy is not a part of the other procedure.

Example #5: 
A scar revision is performed on a painful colloid of a patient's foot, originally caused by stepping on glass five years previously.  The original wound was never sutured.  The procedure is complex, as the scar measures 3.3 cm and the repair is tedious.  During the same session, the physician noted a lesion on the patient's right calf and obtained a skin biopsy.

CPT codes 13132 and 11100-59 are submitted.

Modifiers can be very confusing.  If they are used correctly, your reimbursement may be increased and sometimes, unfortunately decreased.  Overall, modifiers are all about money!  So use them wisely and correctly.  Avoid those denials and underpayments with the correct usage.