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Modifier 59

Distinct Procedural Service

Instructions

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. 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. 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) not ordinarily encountered or performed on the same day by the same individual. Modifier 59 should only be used if no other more specific modifier is appropriate.

Correct Use

Different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

  • Procedures are performed in different encounters on the same day
  • Two services described by timed codes provided during the same encounter only when they are performed sequentially
  • Diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
  • Diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure

Incorrect Use

  • Should not be appended to an E/M service
  • Should not be used inappropriately if the basis for its use is that the narrative description of the two codes is different
  • When another modifier is more appropriate (e.g. modifier 76 or 91)
  • Should not be used to bypass NCCI edits
  • Does not replace modifiers such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI, XE, XP, XS, XU

Example

Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable.

This claim example shows CPT 17000 with no modifiers on the first claim line and CPT 11100 with modifier 59 on the second claim line.

Note: If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Reminders

Records must evidence a different session or patient encounter, different procedure or surgery, different site or organ system, or separate lesion, incision, excision, injury or area of injury

Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

Resource

 

Last Updated Wed, 15 Dec 2021 19:17:14 +0000