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Rev up Reimbursement with Modifier 59

By G. John Verhovshek, MA, CPC

Used appropriately, modifier 59 Distinct procedural service is a powerful reimbursement tool allowing for separate payment of distinct services that, under usual circumstances, would not be billed together. For this same reason, the modifier also allows ample opportunity for misuse and abuse. The competent coder will apply modifier 59 to ensure optimal cash flow with absolute compliance.

Separate/Different May Warrant 59

Basic instruction for applying modifier 59 may be found in CPT® Appendix A -Modifiers begin as such:
“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.”
In other words, when the circumstances warrant, modifier 59 gives you the power to unbundle. Circumstances that may call for unbundling include a documented:

  • Different session
  • Different procedure or surgery
  • Different site or organ system
  • Separate incision or excision
  • Separate lesion
  • Separate injury (or area of injury in extensive injuries)

Appendix A additionally requires the different/separate circumstance to be “not ordinarily encountered or performed on the same day by the same individual.”
Be aware that a “separate location” does not include treatment of contiguous structures of the same organ. For example, according to instruction provided by the Centers for Medicare & Medicaid Services (CMS) (located online at www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf), “treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site.” Likewise, “treatment of posterior segment structures in the eye constitutes a single anatomic site.”
Note also that a different/separate diagnosis is not included among the circumstances supporting modifier 59. The aforementioned CMS guidance is explicit on this matter, stating, “different diagnoses are not adequate criteria for use of modifier -59.” By the same token, however, neither are different diagnoses required to report services separately with modifier 59.
For example, you would not commonly report 38221 Bone marrow; biopsy, needle or trocar and 38220 Bone marrow; aspiration only at the same time: The aspiration is bundled to the biopsy. But if the procedures occurred at different sites (for example, on contralateral iliac crests, or the iliac crest and sternum), via different incisions, or at different encounters, modifier 59 is appropriate to allow for separate payment (38221, 38220-59).
Similarly, typically colonoscopy with biopsy (45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) would be bundled to a more extensive removal (e.g., 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). If, however, the two procedures are performed on separate lesions or at separate patient encounters, separate reporting of the “lesser” service with modifier 59 is appropriate (45385, 45380-59).
Two additional examples illustrating appropriate application of modifier 59 for different/separate circumstances may be found in the July 2000 and June 2002 CPT® Assistant, respectively.
Consider this: If a lesion is removed from the forehead, resulting in a 5.2 sq cm defect, and another lesion is removed from the neck, resulting in a 7.3 sq cm defect, and both require rotational advancement flaps to provide closure, then CPT® code 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less would be reported twice, with modifier -59 appended to the second code. Although both anatomic sites fall into the same anatomic classification as defined by the code descriptor for code 14040, the defects do not have contiguous margins and represent separate and distinct defects.
For example, if multiple bacterial blood cultures are tested, including isolation and presumptive identification of isolates, then use code 87040 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) to identify each culture procedure performed. Append modifier 59 to the additional procedures performed to identify each additional culture performed as a distinct service.

Identify Bundled Procedures

CPT® codes most often subject to bundling are those designated as:

  • Separate procedures (i.e., 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure));
  • Lesser services within the same code family (e.g., when biopsy is bundled to removal, as in the example of 45380/45385, above); or
  • Codes within the same code family describing alternate methods or approaches (e.g., colonoscopy with removal by snare (45385) and colonoscopy with removal by hot forceps (45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery).

CPT® section notes and parenthetical instructions often provide guidance on when procedures may be bundled. For example, CPT® section notes for “Excision – Malignant Lesions” specify, “Excision of lesion (11600-11646) is not separately reportable with adjacent tissue transfer” at the same location.
For Medicare and those payers who follow CMS guidelines, the simplest way to know if two codes are bundled is to consult national Correct Coding Initiative (CCI) edits. If any two codes are listed as “mutually exclusive” or paired together as “column 1” and “column 2” codes, the procedures are bundled and would not normally be reported together. The first listed code always is the “more extensive” procedure, into which the second-listed code would be bundled. If circumstances warrant the use of modifier 59 to indicate a separate incision/excision, etc., always append the modifier to the “lesser” procedure.

Using 59 to Override CCI Edits

Before appending modifier 59 to override a CCI edit, you must be certain that unbundling is allowed for the particular code pair you wish to report as separate/distinct procedures. Each CCI code pair edit includes a correct coding modifier indicator of “0” or “1,” as indicated by a superscript placed to the right of the column 2 code. A “0” indicator means you may not unbundle the edit combination under any circumstances. An indicator of “1” means you may use a modifier to override the edit if the procedures are distinct from one another.
For example, 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less is mutually exclusive of 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia); simple or single), according to the CCI. Code 11400 is the “column 1” (more extensive) procedure. For incision and drainage and lesion excision at the same location, report only 11400 because 10060 is bundled to the excision.
This code pair contains a “1” modifier indicator, however, and you may dismiss the edit if the procedures are distinct from one another. For instance, for incision and drainage and lesion excision at different locations, you would report 11400 and 10060-59. Note the placement of 59 on the “lesser” procedure.

Evaluation and Management – CEMC

When Not to Use 59

CPT® instruction is clear that modifier 59 doesn’t apply to evaluation and management (E/M) codes. CPT® Appendix A, for instance, instructs, “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.” CMS and CCI guidelines stress the same points.
CPT® and CMS guidelines agree that modifier 59 should be the “modifier of last resort.” As CPT® Appendix A explains, “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”
For example, a patient receives an excisional breast biopsy (19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions), which returns positive for malignancy. Several days later, the patient undergoes a modified radical mastectomy (19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).
CCI bundles 19120 to 19307, but because documentation indicates the biopsy led to the decision to perform the mastectomy, the biopsy is separately payable. In this case, however, modifier 59 is inappropriate. Rather, modifier 58 Staged or related procedure or service by the same physician during the postoperative period better describes the circumstances of the staged/more extensive procedure. Proper coding  would be 19120, 19307-58.
A second example of when another modifier would apply before modifier 59 comes from the June 2002 CPT® Assistant:
For example, if three subsequent potassium level blood tests are ordered and performed on the same date as the initial test to obtain multiple results in the course of potassium replacement therapy, then report code 84132 Potassium; serum, once for each blood test performed, and append modifier 91 Repeat clinical diagnostic laboratory test to the subsequent test codes to identify the repeat clinical diagnostic laboratory tests performed.
Microbiology guidelines in the microbiology subsection of CPT® clarify the appropriate use of modifier 91, versus modifier 59, in this situation:
“Presumptive identification of microorganisms is defined as identification by colony morphology, growth on selective media, Gram stains, or up to three tests (eg, catalase, oxidase, indole, urease). Definitive identification of microorganisms is defined as an identification to the genus or species level that requires additional tests (eg, biochemical panels, slide cultures). If additional studies involve molecular probes, chromatography, or immunologic techniques, these should be separately coded in addition to definitive identification codes (87140-87158). For multiple specimens/sites use modifier -59. For repeat laboratory tests performed on the same day, use modifier -91.”
Lastly, never append modifier 59 if documentation does not support the separate/distinct nature of the procedures, and never append modifier 59 to override CCI edits in an attempt to increase reimbursement without justification. This is abusive and likely fraudulent coding that quickly will garner payers’ attention.

G. John Verhovshek, MA, CPC, is AAPC’s director of editorial development–education.

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