Otolaryngology Coding Alert

Question: When should I use modifier -59 instead of modifier -51?


California Subscriber


Answer: You should use modifier -59 (Distinct procedural service) when the National Correct Coding Initiative bundles the two codes that you are reporting. If the codes are not bundled, report modifier -51 (Multiple procedures).

Warning: Make sure that modifier -59 appropriately describes the relationship between the two procedures and that the edits allow a modifier to override the bundle.

Remember, modifier -59 is not a license to unbundle. You may use modifier -59 only when the circumstances match one of these descriptions:
  different session or patient encounter
  different procedure or surgery
  different site or organ system
  separate incision/excision
  separate lesion
  separate injury. Modifier -59 example: An otolaryngologist controls epistaxis in a patient (30903, Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing], any method]). Later the same day, the patient has break-through bleeding, requiring endoscopic hemorrhage control (31238, Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage).

To override the 30903-31238 bundle, you should append modifier -59 to the bundled procedure - the epistaxis control (30903). The modifier tells the payer that the otolaryngologist performed the hemorrhage control in a separate session from the endoscopic nasal hemorrhage control. Therefore, he deserves payment for the epistaxis control.

Modifier -51 example: The otolaryngologist excises two lesions from two different locations: one from the vestibule of the mouth, 40810 (Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair), and one from the tongue, 41110.
 
In this case, you should append modifier -51 (Multiple procedures) to the lesser-valued procedure - 40810. Because you have two separate CPT codes that are not bundled, you can report both codes.

Exception: Do not automatically use modifier -51 on Medicare claims. Some Medicare carriers will append it for you. Answers to You Be the Coder and Reader Questions provided/reviewed by Andrew Borden, CCS-P, CPC, CMA, reimbursement manager in the department of otolaryngology and communication sciences at Medical College of Wisconsin in Milwaukee; Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a physician billing firm in Brick, N.J.; and Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.