PIP PRACTICE TIP: PROPER USE OF MODIFIER -59 FOR REIMBURSEMENT OF SERVICES THAT ARE “SEPARATE AND DISTINCT” FROM OTHER SERVICES BILLED ON SAME DATE
The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.
It is important for medical providers to correctly use modifier 59 in order to receive reimbursement for codes that are indeed “separate and distinct” from other services billed on the same date of service. Modifier 59 is defined by the CPT Manual as follows:
“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-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. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”
To summarize, modifier 59 is used to indicate a separate and distinct procedural service for surgical procedures, non-surgical therapeutic procedures or diagnostic procedures that were independent of other services performed on the same day, including, but not limited to the following:
- Different session
- Different site or organ
- Separate excision/incision
- Separate lesion
- Separate injury.
The Medicare National Correct Coding Initiative (“NCCI”) promulgated edits, which contain pairs of CPT codes that generally should not be billed together by a provider for the same patient on the same date of service. Under certain circumstances, a provider may bill for two services in a NCCI code pair and include a modifier that would bypass the edit and allow both services to be paid.
Modifier 59 is one of over thirty modifiers that can be used to bypass an NCCI edit conflict. A modifier, however, cannot be appended to a CPT Code for the sole purpose of bypassing an NCCI edit if the clinical records do not justify its use. Modifier 59 is used to represent that a provider performed a separate and distinct procedure or service for a patient on the same day as another procedure or service. Modifier 59 should be attached to the secondary, additional, or lesser service in an NCCI code pair. Pursuant to the “Medicare Claims Processing Manual,” in order to properly bill with modifier 59, the provider’s documentation must show that the service was distinct from other services performed that day.
A common misuse of modifier 59 is when a medical provider uses it on the sole basis that the narrative description of the two codes is different. The two “different procedures” must be performed at separate anatomic sites or at a separate patient encounter on the same date of service in order to justify the use of modifier 59.
Notably, the treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites and should not be billed with a 59 modifier. For instance, arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site.
Modifier 59 should only be used in circumstances where no other modifier more appropriately describes the relationship of the two procedure codes. For example, if two procedures are performed on different sides of the body, modifiers RT (“right”) and LT (“left”) or another pair of anatomic modifiers should be used, not modifier 59.
In sum, modifier 59 is used appropriately in the following circumstances:
- for 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;
- when the procedures are performed in different encounters on the same day;
- when two timed procedures are performed in different blocks of time on the same day;
- for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure;
- for a 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.
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