Gastroenterology Coding Alert

The keys to understanding modifier -59 perhaps the trickiest modifier in the book can be found in the book itself.

The definition of modifier -59 (Distinct procedural service) found in the CPT manual lists three components that provide a checklist for coders to follow.

First, the modifier is intended to describe separate, distinct procedures or services that are performed on the same day by the same physician, says John Lavere, MBA, CPC, director of compliance, Charlotte, N.C. "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day," states CPT 2002, Appendix A, page 382.

Second, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances," according to CPT. You should not use the modifier to indicate another procedure that is often performed with the primary procedure, but make sure that both procedures are not normally reported together.

"Modifier -59 is not a universal unbundler," says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "You should not consider the modifier a way to unbundle procedures or services."

"Use a -59 to explain that a procedure which is usually bundled is separate and distinct in this particular situation," agrees Staci Jordan CPC, CCS-P, reimbursement analyst for the University of Oklahoma Health Sciences Center in Oklahoma City. "Check the Correct Coding Initiative for procedures which CMS designates as incidental and require modifier -59 for separate payment," she says.

CCI states, "A 1 indicates that a modifier is allowed in order to differentiate between the services provided."

Third, the definition provides examples of typical situations that the same physician may not ordinarily encounter or perform on the same day that warrant modifier -59. Those examples include:
a different session or patient encounter a different procedure or surgery a different site or organ system a separate incision/excision "Look at modifier -59 as a tool," Cobuzzi says. When you receive denials that you disagree with, consider using modifier -59 if you can apply its definition to the particular situation at hand.

"Modifiers tell a story about why something should be paid more or paid less." They help carriers understand why two procedures that an insurer would not normally reimburse separately should be paid that way.