Use It, Dont Abuse It:
When To Append Modifier -59
Published on Tue Jan 01, 2002
Modifier -59 (distinct procedural service) is important because it enables neurosurgeons to receive separate reimbursement for procedures that are usually bundled if provided on the same date of service, but that in a particular instance were distinct or independent of one another. But just as proper use of modifier -59 can increase a surgeon's bottom line, improper use or abuse can lead to denied claims, audits or allegations of fraud.
When Is -59 Appropriate?
According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." In essence, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, owner and CPC trainer for A+ Medical Management and Education in Absecon, N.J, modifier -59 tells the insurer, "Although these services/procedures appear related, they are, in this case, separate." Such circumstances may include:
A different session or patient encounter.
A different procedure or surgery.
A different site or organ system (perhaps the most common use of the modifier).
A separate incision/excision, lesion or injury or area of extensive injury not ordinarily encountered or performed on the same day by the same physician.
Specifically, modifier -59 is used to unbundle national Correct Coding Initiative (CCI) code pair edits. For instance, the surgeon performs a lumbar decompression followed by a lumbar microdiskectomy at a different level. Each procedure was associated with a different diagnosis. The coder may report 63047 (laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) and 63030 (laminectomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) together with separate diagnoses. CCI bundles these procedures, but the edit includes a "1" indicator. Therefore, modifier -59 can be attached to the microdiskectomy to indicate that it was performed at another location.
But if the surgeon extends the laminectomy to remove a disk at the adjacent level, modifier -59 may not be used because the procedure is not occurring at a separate anatomical area.
More Coding Examples
Modifier -59 is used frequently to override CCI edits in neurosurgical coding. For instance, 22630 (arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) includes laminectomy, facetectomy and diskectomy to prepare the interspace for posterior lumbar interbody fusion, and CCI bundles it with 63047 (laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar). Once again, the edit includes a "1" indicator, and a modifier may be used [...]
