Advanced Search

Pulmonology Coding Alert

Modifier -59:

Know When to Use It and When to Avoid It

Published on Sun Dec 01, 2002

Using modifier -59 (Distinct procedural service) can optimize a pulmonologist's bottom line, but improper use or abuse can lead to denied claims, audits or allegations of fraud.

Modifier -59 is important because it enables pulmonary physicians to receive separate reimbursement for procedures that are usually bundled if provided on the same date of service, but that in a particular instance are distinct or independent of one another.

"Modifier -59 was created in response to Medicare's Correct Coding Initiative [CCI]," says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C. She explains that Medicare accepts this modifier when the physician uses it to show that services that are normally bundled by CCI are not integral to the comprehensive service the physician performed, but distinct and separately reportable.

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." Such circumstances may include the following:

  • a different session or patient encounter
  • a different procedure
  • 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, physicians use modifier -59 to unbundle CCI code-pair edits. For example, a pulmonologist performs a bronchoscopy with transbronchial lung biopsy with fluoroscopic guidance for the right lung and then a bronchoscopy with biopsy on the left lung. Because the physician took the biopsies at different sites, you should report 31628-RT (Bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance; right side) and 31625-59-LT (... with biopsy; left side), says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.

    "Commercial payers may base their bundles on CPT guidelines and definitions, separate procedure designations, or the internal policies of the individual payer," Richardson says. "Because CCI is CMS' program, you should be aware of whether or not your payers follow Medicare's bundling guidelines or if they have their own bundling guidelines."

    Modifier -59 Is Not a Magic Wand

    CPT instructs coders that modifier -59 is not a "catchall" and should be reported only if no other more specific modifier applies, e.g., modifiers -51 (Multiple procedures), -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period).

    For example, a pulmonologist sees a patient having an acute asthma attack. The physician has to administer two inhalation treatments in one day, due to the severity of the patient's condition. Modifier -59 would not be reported with 94640 (Nonpressurized inhalation treatment) because modifier -76 (Repeat procedure by same physician) is more appropriate. This ties into one of the new cross-references for 94640 in CPT 2003.

    And modifier -59 should never be appended to E/M codes. Rather, to be paid separately for an E/M service that is provided in addition to another procedure or service on the same day, you report the appropriate E/M code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

    Reimbursement and Documentation

    Unlike some modifiers (e.g., -51), modifier -59 should not lead to reduced reimbursement. You should not reduce your fees when billing, and you should appeal if the payer reduces or denies your modifier -59 claims. "If the physician reports a reduced fee, the third-party payer may assume it is their full fee and further reduce the charge," Revel says.

    In some cases, reimbursement with modifier -59 is carrier- or situation-driven. If this is the case, you may protest the reduction, but be sure to get the carrier's guidelines in writing and follow them.

    "I find that many payers automatically apply the multiple surgical payment policy even when modifier -59 is applied to a CPT code," Revel says. "Therefore, I encourage all physicians to get a copy of the applicable payment guidelines from their top-10 third-party payers."

    According to the AMA's CPT Assistant, modifiers -51 and -59 should not be appended to the same CPT code. Modifier -51 has four applications, namely to identify:

  • Multiple medical procedures performed at the same session by the same provider
  • Multiple related operative procedures performed at the same session by the same provider
  • Operative procedures performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy
  • A combination of medical and operative procedures performed at the same session by the same provider.

    Because modifier -59 can unbundle CCI edits and generate more revenue for your practice, payers often specifically scrutinize claims containing it. You should not use modifier -59 indiscriminately as a way to increase reimbursement or protest CCI edits.

    Although you do not have to include full notes with every claim as you might with modifier -22 (Unusual procedural services), be aware that because modifier -59 can override most CCI edits and thereby provide additional payment, the insurer may request additional documentation. Therefore, you should always keep thorough notes to substantiate using modifier -59 (whether to collect a claim or in case of an audit). Also, using different diagnoses when applicable for each CPT code will help to establish medical necessity.

    • Other Articles in this issue of

    Pulmonology Coding Alert

    View All