59 - JE Part A

Definition

Distinct Procedural Service

Appropriate Usage

• Append when documentation indicates two separate procedures performed on same day by same physician
  • Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)
• Append to secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits
  • Indicate 0 means a Correct Coding Modifier (CCM) is not allowed
  • Indicate 1 means a Correct Coding Modifier (CCM) is allowed
  • Indicator 9 means the use of a CCM is not specified
• Append when there is NO other appropriate modifier
• Append on second initial injection procedure code when IV protocol requires two separate IV sites or when patient has to come back for a separately identifiable service

Inappropriate Usage

• Code combination not appearing in NCCI edits
• Submission of E/M Codes
  • Includes ophthalmology codes 92012-92014
• Submission of weekly radiation therapy management codes (CPT 77427)
• The NCCI tables lists procedure code pair with a modifier indicator of "0"
• Documentation does not support the separate and distinct status
• Exact same procedure code performed twice on same day
• Multiple administration of injections of same drug
• When a more specific modifier exists to identify the services

Reminders

When a provider or supplier submits a claim for any of the codes specified (i.e., 77427, 92012-92014, and 99201-99499) with the 59 modifier or XE, XP, XS, XU, the A/B MAC shall process the claim as if the modifier were not present

Resources

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.9
• CMS Medicare National Correct Coding Initiative (NCCI) Edits
• Proper Use of Modifiers 59 & -X{EPSU}