Modifier 59 - What You Need to Know

Under certain circumstances, it may be necessary to indicate a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services, other than Evaluation and Management (E/M) services, that are not normally reported together, but are appropriate under the circumstance.

Modifier 59 is the most commonly reported modifier that affects National Correct Coding Initiative(NCCI) processing. The Medicare NCCI includes Procedure-to-Procedure (PTP) edits that define when two codes, Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT), should not be reported together.

PTP associated edits will have a Correct Coding Modifier Indicator (CCMI)

  • 0 - Codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the code in column one is eligible for payment and the column two code is denied.
  • 1 - Codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI associated modifiers.
  • 9 - NCCI editing does not apply.

When documentation supports, modifier 59 may be reported to indicate that a procedure or service was distinct or independent from other services performed on the same day. The code descriptors of a code pair edit usually represent different procedures, even though they may overlap. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered “separate and distinct.”

Common uses of modifier 59 are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day, and cannot be described by one of the more specific anatomic modifiers. The following are NCCI PTP associated modifiers:

  • Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
  • Global surgery modifiers: 24, 25, 57, 58, 78, 79
  • Other modifiers: 27, 59, 91, XE, XS, XP, XU

Modifier 59 Appropriate Uses (reference Medicare Learning Network (MLN) Matters Special Edition (SE) 1418):

  • Different session
  • Different procedure or surgery
  • Different site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service
  • Separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
  • No other appropriate modifier is available. Evaluate other modifiers such as the RT/LT to identify right and left, F1-F0 to identify fingers, T1-T0 to identify toes and E1-E4 to identify eyelids

The Centers for Medicare & Medicaid Services (CMS) established four HCPCS modifiers to provide greater reporting specificity in situations where modifier 59 was previously reported.

  • XE - “Separate encounter, a service that is distinct because it occurred during a separate encounter;”
  • XS - “Separate Structure, a service that is distinct because it was performed on a separate organ/structure”
  • XP - “Separate Practitioner, a service that is distinct because it was performed by a different practitioner”
  • XU - “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service”

Note: May append modifier 59 or the appropriate XE, XS, XP or XU modifiers. CMS allows, but has not mandated the use of the newer modifiers at this time.

Modifier 59 Inappropriate Uses:

  • Another established more descriptive modifier is available
  • To bypass a NCCI PTP-associated edit unless the proper criteria for use of the modifier are met.  Documentation in the medical record must satisfy the criteria required by any NCCI PTP-associated modifier that is used.
  • With E/M codes 99201-99499 (refer to modifier 25)
  • A valid modifier exists to identify the services
  • Documentation does not support the separate and distinct status
  • To indicate multiple administration of injections of the same drug
  • NCCI tables lists the procedure code pair with a modifier indicator of "0"

Repeat Procedure on same day
When billing repeat procedures (same HCPCS/CPT code) on the same day, for the same patient, append an appropriate repeat modifier to the second or subsequent procedure code. Modifier 59 would not be appropriate. Common repeat modifiers include:

Resources:
Modifier 59 Article
Change Request 11168
MLN Matters Number SE1503
MLN Matters Number SE1418
CMS Internet Only Manual (IOM) - Claims Processing Manual, Pub. 100-04, Chapter 23, Section 20.9

 

            Last Updated Fri, 30 Oct 2020 16:15:36 +0000