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Get Paid Using Modifiers 50, 51, 59

Get Paid Using Modifiers 50, 51, 59

Know when to use these modifiers and how they affect reimbursement.

Surgical modifiers 50 and 52 and modifier 59 are crucial to telling the story of a claim by identifying procedures that have been altered, without changing the core meaning of the code(s) submitted. Let’s focus on proper application and instructive resources for these three modifiers.

What is Modifier 50?

Surgical modifier 50 Bilateral procedure describes procedures/services that occur on identical, opposing structures (e.g., eyes, shoulder joints, breasts). Follow these rules for appropriate use:
  • Do use modifier 50 on bilateral body organs, such as the kidneys, ureters, and hands.
  • Do not append modifier 50 to procedures on the skin because the skin is one organ.
  • Do use modifier 50 when the code description does not already state the procedure is bilateral.
  • Do not use modifier 50 when “one or both” is in the code description.

When deciding whether to use modifier 50, it’s sometimes difficult to determine if the procedure is considered bilateral. An easy way to tell is to consult the Medicare Physician Fee Schedule (MPFS).  A table, similar to the condensed version shown in Table A, identifies which procedures Medicare identifies as bilateral. Remember: Commercial carriers may follow their own guidelines.

Example A in Table A indicates that code 68840 Probing of lacrimal canaliculi, with or without irrigation has a bilateral surgery indicator of 1. This denotes that the procedure is unilateral, as described in CPT®, and can be appropriately billed as a bilateral procedure with modifier 50 appended. Medicare will pay this procedure at 150 percent of the allowed amount, subject to the patient’s deductible and coinsurance. Be sure to increase the billed amount when the claim is submitted; Medicare will not increase this amount on its own. As an example, if the allowed amount for 68840 is $100, the coder should increase the billed amount to $150 on the claim form.


Example B indicates code 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy has a bilateral surgery indicator of 0. This procedure code cannot be billed as a bilateral procedure because the thyroid is not a bilateral body part. When the indicator 0 is designated, it means that the physiology, anatomy, or the code descriptor specifically states the procedure is unilateral or there is an existing code for the bilateral procedure. Never append modifier 50 to these procedures.

In Example C, code 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) has a bilateral indicator of 2. These procedures are considered “inherently bilateral,” which means the code descriptor or procedure specifically includes bilateral body parts. In this example, the code descriptor includes bilateral lymph nodes and, dependent on the extent of the procedure, the fallopian tubes and ovaries. The allowed fee schedule for inherently bilateral procedures already includes payment for a bilateral service, so modifier 50 should not be used and the billed amount should not be increased.

A bilateral indicator of 3 (not shown here because it does not apply to surgery procedures) is considered “independently bilateral,” and usually applies to radiology procedures and diagnostic tests. These codes are considered bilateral if modifier 50 is present; and full payment should be made for each procedure. One such code is 73080 Radiologic examination, elbow; complete, minimum of 3 views. For example, if this procedure is performed on both the left and right elbows, and one procedure has an allowed amount of $100, the total allowed amount for 73080-50 would be $200.

Different carriers require different reporting of bilateral procedures and offer different reimbursement methodologies. For examples of common carrier preferences, see Table B.

Check your carriers’ online medical policy base or review your physicians’ contracts for instructions on applying modifier 50 properly on claims forms.

What is Modifier 51?

Surgical modifier 51 Multiple procedures indicates that the same provider performed multiple procedures — other than E/M services — at the same session. You should list the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and subsequent procedures.
Use modifier 51 to indicate:

  • Same procedure, different sites
  • Multiple operation(s), same operative session
  • Procedure performed multiple times

Most payers apply a “multiple procedure discount” with modifier 51. This refers to the practice of reducing the reimbursement for subsequent procedures because of shared resources when two or more procedures are performed together. CPT® Appendix E lists codes that are exempt from modifier 51.

The following is an example of multiple operations in the same operative session:
Scenario: The patient presents for removal of a 0.5 cm (as measured by CPT® guidelines) malignant skin lesion on the trunk. A layered closure of the resulting wound is performed in the same operative session. The appropriate coding is:
12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less [typically 100 percent allowed reimbursement*]
11600-51 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less [typically reduced reimbursement*]

*Dependent on carrier policy. You should also note that a few carriers may automatically order the procedure codes based on that carrier’s fee schedules.

What is Modifier 59?

CPT Modifier 59 Distinct procedural service is used to indicate:

  • Different session or encounter
  • Different procedure
  • Different site
  • Separate incision, excision, lesion, injury, or body part

Modifier 59 is frequently appended to those codes defined as “separate procedures” in CPT®. Designated separate procedures commonly are carried out as an integral component of a more extensive procedure. Only when a procedure or service designated as a separate procedure is carried out independently, and is considered to be unrelated or distinct, may it be reported separately.

For example, 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) is a designated separate procedure. If this procedure is:

  • Performed alone (e.g., on the left knee): Report 29870-LT.
  • Performed as an integral part of another procedure (e.g., a diagnostic arthroscopy and surgical arthroscopy on the right knee): Do not bill the separate procedure. Code only the surgical arthroscopy 29866-RT Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]).
  • Performed as a distinct procedure (e.g., a diagnostic arthroscopy on the left knee and a surgical arthroscopy on right knee in same surgical session): Report 29866-RT and 29870-59-LT. As with modifier 51, list first the more resource-intense procedure (in this case, the surgical approach).

In another example, the patient presents for an excision of a right arm skin lesion, which is benign, and a biopsy of a skin lesion on the left arm. These codes usually are not reported together because CPT® instructs, “the obtaining of tissue for pathology during the course of [surgical procedures in the integumentary system] is … not considered a separate biopsy procedure and is not separately reported.” In this case, however, the procedures are performed on two distinct body sites, and we are further instructed, “The use of a biopsy procedure code (e.g., 11100, 11101) indicates that the procedure … was unrelated or distinct from other procedures/services provided at that time.”
The appropriate coding is:

  • 11403 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm for the right arm skin lesion excision, with ICD-9-CM code 216.6 Benign neoplasm of skin; skin of upper limb, including shoulder
  • 11100-59 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion for the left arm skin lesion biopsy, with ICD-9-CM code 238.2 Neoplasm of uncertain behavior of other and unspecified sites and tissues; skin

Once again, you should list first the more resource-intense procedure (the benign lesion excision). Follow that with the biopsy, appending modifier 59 and linking it with the “uncertain behavior of neoplasm” diagnosis code.

The Difference Between Modifiers 51 and 59

According to CPT®, when multiple procedures are performed at the same session by the same provider, you may identify the additional procedure(s) or service(s) by appending modifier 51. CPT®, however, also instructs us to use modifier 59 to identify two procedures or services that are not usually submitted together, but are appropriate under the circumstances. CPT® further instructs us not to use modifier 59 if another already established modifier is appropriate. This is how modifier 59 earned its nickname, “The modifier of last resort.”

When choosing between modifiers 51 and 59, payer policy may be the determining factor. Some payers, including Medicare contractors, do not acknowledge modifier 51. And, though we should not code solely based on reimbursement, keep in mind that modifier 51 may trigger the multiple payment reduction. On the other hand, modifier 59 may trigger a front-end edit, and the payer may require documentation, which will inevitably delay claim reimbursement.

A good reference are the National Correct Coding Initiative (NCCI) edits, which provide directions on when to appropriately “unbundle” procedure codes, as illustrated in Table C. NCCI edits are valid for Medicare only, but other payers are permitted to follow these guidelines. You can find NCCI resources on the CMS website).

NCCI edits are referred to as Column 1 and Column 2 codes: Column 1 is the reimbursable code; and column 2 is not payable unless a modifier is permitted and submitted. An edit of 1 in the first pair of codes indicates that the column 2 code is a component of the column 1 code, but can, at times, be billed separately with modifier 59 appended. The first pair of codes in Table C relate to the example previously reviewed. In this example, the procedures were performed on different sites, so the use of modifier 59 is correct.

The second set of codes, 11100 and 99149 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; age 5 years or older, first 30 minutes intra-service time are listed with a 0, which indicates that they cannot be billed together using any modifier.

The last code pair, +11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) and the column 2 code of 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single are assigned a 9 indicator. This means that an NCCI edit does not apply to this code pair. If the procedures were performed in the same operative session, use modifier 51 for multiple procedures on the column 2 code (10060), based on carrier policy.

Nancy Clark

About Has 14 Posts

Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, has over 20 years of experience in medical coding and billing, healthcare consulting, accounting, and business administration. She applies her skills to assist physician and hospital clients with revenue cycle management. Clark focuses on coding and documentation reviews, assistance with payer audits, and providing education for physicians and their staff. She is also an AAPC certified instructor, a contributing author to health care publications, and a presenter at seminars. Clark is a member of the Novitas Medicare Provider Outreach and Education Advisory Group and co-founder of the New Jersey Coders' Day Medical Coding and Billing Conference. She is proud to support the AAPC for recognizing the value of medical coding professionals and enjoys working with its members.

25 Responses to “Get Paid Using Modifiers 50, 51, 59”

  1. Tim Lowney says:

    I am in an outpatient primary care setting. I had a patient in for a physical but also wanted to discuss several other issues and needed a cerumen removal. In this situation we billed for the preventive visit w 25 modifer and office visit with cerumen removal. It looked like this:
    Is this correct or can you add a 25 modifier to the 99213 as well as the 99395?

  2. Kar says:

    I have a few questions to ask since modifier are confusing.
    1. If the left and right knee has diagnostic arthroscopy, do you use modifier 50 for bilateral since this is left and right side of the knee? Second, do you attach modifier 59 since this is more than one procedure? Third, how would the order of coding sequence be, do you code left first or right first or it doesn’t matter?
    2. With the skin closure, the example given above with malignant excision and layered closure, why is the layered closure code first then the excision code? How do you tell excision is not more difficult than the layered closure?

  3. Jody says:

    I have a question about billing modifier 50 with 51. I know that we do not need to apply modifier 51 anymore to our codes but we use them for RVU purposes for our reports. The codes that I am looking at are 3622650 and 3622350, since these codes are already reduced with the modifier 50 would we apply 51 modifier to the second procedure?
    any information is greatly appreciated.
    Thank you!

  4. Yesi says:

    what do you use for a colonoscopy and endoscopy done on the same day?

  5. sandi says:

    I have a question on denials I’ve received for inpaitent hospital visits and cardio tests that are on the ncci list. example
    same physician billed 99232 and test performed same date and read by physician 93016 and 93018. what is the correct modifier to use , or is this just not billable separately? how should we proceed? thanks

  6. swapna says:

    what can we use it Centraline placement and ET tube on same day , kindly advice.

  7. Beth says:

    Which modifier is more appropriate for a colonoscopy, flexible; with removal of tumor, polyp or other lesion by snare technique (45385) and colonoscopy, flexible; with biopsy, single or multiple (45380) are performed during the same session? -51 or-59, -xs, or -xu?

  8. Marcus says:

    Same day billed 99232(GV) & 12001 billed Medicare both Cpt same Dx. Kindly please advice which modifier can we using for Cpt 99232

  9. Nicole says:

    What modifier is adviced to be used for procedure 36415 when performed more then once? I have seen it with a 59 and 76.

  10. QUDDUS says:

    76 it is correct. if it will wrong i will resing the my job

  11. prashanth shetty says:

    naku telisinde right

  12. Doretha says:

    I am filing this code to Medicare CPT 76377 does this code need a modifier ? if so what modifier do you use?
    thank you for your assistance

  13. Janet says:

    What modifiers would you use for Medicare with cpt codes
    11622 x2 [any modifiers on this line?)
    11622 mod 76
    99214 mod 25
    And Medicare only covers 2 units per day on cpt 11622. And 3 of them were all done on same day.
    Thank you

  14. Corie says:

    I have a billing question for the use of Modifier 59 on code 63655 and 63685. I work at an Ambulatory surgery center. Would you use modifier 59 on these codes

  15. Ashmy A baby says:

    I have a modifier question doubt.if the procedure is performed in the same session is in the right and left side of the body, but it cannot describe
    the term bilateral. can i use modifier 50 in this case.

  16. Anita Rago says:

    I have a question about modifier 51. When should I use modifier.51? Multiple procedures??
    Thank you

  17. Anita Rago says:

    I have a question about modifier 51. When do I use this modifier? Multiple procedures.?
    99203 25
    17000 51, 59?

  18. Julie Hernandez says:

    I have a anesthesia code billed 01402,QK,P2 processed and paid but the other add on 64447,AA,P2,59 denied for invalid combination of HCPCS modifiers. How are the modifiers to be arranged for correct processing?

  19. John B says:

    For question above regarding 64447-AA-P2-59 denial. AA and P2 are an anesthesia service specific modifiers. Anesthesia services are code set 00100-01999 in CPT. Although 64447 is a nerve block that involves injection of anesthetic agent, this is considered a nervous system procedure so not within the parameters for use of the anesthesia modifiers.

  20. Holly Campbell says:

    Is it ever a problem for payers if modifier 59 is listed on the primary or first procedure of a claim, rather than subsequent procedures billed?

  21. Darlene says:

    I cannot seem to find a Modifier 51 exempt CPT Code list. Is one available? I’m trying to find out if we bill for CPT Code 36475 and 36476, is 36475 exempt from the multiple procedure rule since it is an add-on code?

  22. Tracy says:

    Billing 20610 LT for left knee and 20610 LT XS for left shoulder. Anthem is denying 20610 LT as missing/incorrect bilateral modifier, but this is not a bilateral procedure so I can not use a 50 modifier. Any suggestions?

  23. Teresa McClure RN says:

    My question is in regards to the 51 modifier. The pt. was involved in an MVA, and came to the physician with several injuries. He was taken to surgery, and the physician repaired the injuries at the same session. A couple of my physicians believe that the 51 modifier does not apply to “traumatic injuries”. All I have found, in my hunt, is that since the procedures were performed in 1 session, it is correct to use the 51.

  24. alvarado says:

    I have a question. If we are billing a 99309 SNF follow up code and a incision code 10060 do we use a 59 on the 10060?

  25. juanita o says:

    I post cat scans and ive been using modifier 51 if im billing more than one cat scan but I just started receiving denials and im being advised to use the modifier 59 instead. Is this just with medicare or should I use it across the board with all insurances? thank you
    cat scan 74178 -59 modifier now?