General Surgery Coding Alert

Question: One of the coders in our department insists that we can use modifier 59 if the surgeon performs a "separate procedure" for a diagnosis different from the diagnosis that prompted the primary procedure. In looking over Medicare and CPT guidelines, however, I see nothing to support this. Is a separate diagnosis enough to warrant modifier 59?

Maine Subscriber

Answer: According to CPT instructions and Chapter 1 of the national Correct Coding Initiative (CCI), you may append modifier 59 (Distinct procedural service) when the physician:

- sees a patient during a different session

- treats a different site or organ system

- makes a separate incision/excision

- tends to a different lesion

- treats a separate injury.

Although the diagnosis that prompts the follow-up procedure with modifier 59 may be different from the diagnosis that prompted the primary procedure, a different diagnosis by itself does not justify using modifier 59.

Example: A patient comes in for a colectomy for colon cancer, but the patient also has a ventral incarcerated hernia that requires a complex repair using mesh. CCI bundles hernia repair (49560, Repair initial incisional or ventral hernia; reducible) to the partial colectomy (44140, Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure.

Wrong way: You would not want to tack modifier 59 onto the hernia repair code and report it separately -- even though the hernia repair is for a totally different reason than the colectomy. In this case, modifier 59 tells the payer the hernia repair happened at a separate session, which isn't true. Because the hernia repair is integral to the same-session colectomy, you can't report it separately.

Correct way: Instead, you could try appending modifier 22 (Unusual procedural services) to the colectomy (44140) because of the extra time and effort the complex hernia repair requires. Make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation. Even then you may have to appeal to recover additional reimbursement.

Bottom line: Append modifier 59 to a claim only if you are certain of the involved procedures- distinct nature (regardless of the diagnoses) and never simply to override CCI bundles and get paid.