What is CPT Modifier 59 for Medicare Billing

The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits and they are very helpful in some particular situation. These edits define when two Healthcare Common Procedure Coding System (HCPCS) should not be reported together either in all situations or in most situations. For PTP edits that have a Correct Coding Modifier Indicator of 0, the codes should never be reported together by the same provider for the same beneficiary on the same date of service.

So it’s important that procedures should be separately reported because If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied. But there are some defined circumstances, when the codes may be reported together which are identified on the claim by the use of specific NCCI-associated modifiers. One of the main functions of NCCI is to prevent payment for codes that report overlapping services. As discussed there are some exceptions where the services are separate and distinct.

It is important to verify whether the services are bundled through CCI, before submitting this modifier. Code pairs with indicator 0 in the CCI list cannot be submitted separately for reimbursement under any circumstances. While code pairs identified with indicator 1 may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury.

CPT Modifier 59 for Medicare Billing

Under certain circumstances, the physician must indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is one of few modifiers that are often used incorrectly. Following are some appropriate as well as inappropriate situations in which Modifier 59 is being used.

• Modifier 59 is used appropriately for different anatomic sites during the same encounter only when: 1. procedures which are not ordinarily performed 2. procedures if encountered on the same day but are performed on different organs, 3. different anatomic regions are there, 4. procedures performed in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
•  Documentation must support a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician. 
•  Modifier 59 is commonly used for surgical procedures and non-surgical therapeutic procedures. It is also used for diagnostic procedures that are performed at different anatomic sites, not encountered on the same day, and that cannot be described 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.
•  In addition to above mentioned situations, there are three other limited situations in which two services may be reported as separate and distinct.

1.   Modifier 59 is used appropriately for two services described by timed codes provided                during the same encounter only when they are performed sequentially. If two timed services      are provided in blocks of time that are separate and distinct, modifier 59 may be used to  identify the services. 
2.  Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic          procedure only when the diagnostic procedure is the basis for performing the therapeutic            procedure.
3. In case of diagnostic procedure that precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure but it should be performed before therapeutic procedure.

• The primary purpose of CPT modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It is usually used when no other modifier more appropriately describes the relationship of the procedure codes. 
• Different anatomic sites includes different organs or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ.
• No special documentation is required with the claim when CPT modifier 59 is submitted. 
• When another modifier is appropriate, it should be used rather than CPT modifier 59. 
• Under most circumstances, CPT modifier 59 is not appropriate for use with E/M or surgical procedure codes. One exception is multiple facet joint injections. 
• An inappropriate use of Modifier 59 is when the narrative description of the two codes is different. One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a different procedure or surgery.