How to Use Modifier 59 in Medicare Claims

Modifier 59, the distinct procedural service modifier associated with Medicare National Correct Coding Initiative (NCCI) edits, is one you might find confusing (many practices do). Follow these guidelines when using the modifier to bypass an NCCI edit.

  • A common correct use of modifier 59 is for surgical procedures, nonsurgical therapeutic procedures, or diagnostic procedures that you performed at different anatomic sites and ordinarily would not perform on the same day, and that you cannot describe by one of the more specific anatomic NCCI-associated modifiers  i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

    Under NCCI, "different anatomic sites" means different organs or, in certain instances, different lesions in the same organ. Typically NCCI edits prevent the billing of lesions and sites not considered separate and distinct. Thus you would use modifier 59 to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. Note that the treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites.

  • A common incorrect use of modifier 59 is applying it on the basis of the narrative description of the two codes of the code pair being different. The descriptors of the two codes of an NCCI code pair edit usually represent different, although possibly overlapping, procedures. The edit indicates that when you perform them at the same time on the same anatomic site, those procedures are not considered "separate and distinct," and you should not bill them together. Therefore, don't use modifier 59 simply based on the two codes being "different procedures." However, if you perform the two procedures at separate anatomic sites or at different times on the same date of service, you may append modifier 59 to indicate that they are different procedures on that date of service.
  • Other correct uses of modifier 59 are for:

    • Surgical procedures, nonsurgical therapeutic procedures, or diagnostic procedures you perform during different patient encounters on the same day that you cannot describe with one of the more specific NCCI-associated modifiers 24, 25, 27, 57, 58, 78, 79, or 91.
    • Two services described by timed codes you provide during the same encounter only when you perform them sequentially (i.e., one service is completed before the subsequent service begins).
    • A diagnostic procedure you complete before you begin a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. If the diagnostic procedure is an inherent component of the surgical procedure, do not bill it separately.
    • A diagnostic procedure you perform subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. If the post-procedure diagnostic procedure is an inherent component of or otherwise included in the therapeutic procedure, do not bill it separately. 
     

Remember, any time you use modifier 59, your documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries). Don't use the modifier to bypass an edit unless you've met the criteria for its use.

The Centers for Medicare & Medicaid Services provides a series of examples of how to use modifier 59 (PDF) in various circumstances, and the full CPT definition, in MLN Matters No. SE1418 Revised.

Have coding or billing questions? Contact TMA's certified coders at (800) 880-1300, ext. 1414 or at paymentadvocacy@texmed.org for help.

Published June 10, 2014 
 

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