Modifier 59 and 51

KFLYNN70

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I am trying to figure when its appropriate to add modifier 51 or modifier 59.

Example- I have 2 codes, 25116 and 64721 and the DR would like to apply 59
I disagree, Can someone please advise

dx 354.0
dx 727.05
thanks
 

mhstrauss

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Modifier 51 is appropriate in this case. Modifier 59 is generally used to bypass CCI edits when the services qualify. However, these 2 codes are not listed together in the edits, so no bundling issue. Claim should look like this:

25116 dx 727.05
64721-51 dx 354.0


Hope this helps!
 

lblandin

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Codes 25116 and 64721 are bundled per CCI edits. In this case it would be appropriate to add a modifier 59 to 64721. Modifier 59, Distinct Procedural Service, is intended to be used to indicate that a procedure or service is distinct or independent from other services or procedures performed on the same day. This modifier is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.
 

mhstrauss

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Laura, would you mind posting where you found this info? I checked before I posted, and just rechecked again, and am not seeing what you are. Appreciate any input you can give, I am still fairly new at this.

Thanks!
 

kandigrl79

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I agree with Laura. These two codes have a '1' indicator on the CCI edits which means they are billable under certain circumstances, but would require modifier 59.
 

kdbeale

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Here's my opinion: If documentation justifies it, I'd say 59 mod but let me show you how I came to this.
Go to cms.gov or just search "CMS NCCI PTP" (PTP means: Procedure to procedure):
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
You'll see links at the bottom of the page for hospital & for practitioner. You'll also see effective dates (choose the effective date for your DOS.) You'll see at the tail end of the links code ranges. You have 2 codes, 25116 & 64721 so choose this link:
Practitioner PTP Edits v25.2 effective July 1, 2019 (561,060 records) 0001M/36591 – 26992/G0471
You'll see "column 1" codes & "column 2" codes. Column 2 is bundled with column 1 or in other words, it's a component of column 1 and not separately payable except for certain circumstances. This is where the mod indicator column comes in
"0" means no mod allowed: the code in column 2 is never allowed with the code in column 1
"1" means a modifier is allowed (make sure documentation justifies) this would usually be your mod 59
"9"
mean N/A and this is where your 51 mod would be more likely (of course, depending on payer)
For your example: Use Control/F to do a search for your code, 64721 You'll see the code appears multiple times (there are easier ways to search: export to excel for example) This one happens to come up easily. You'll see 25116 in column 1 & 64721 in column 2 (meaning 64721 is normally bundled with 25116, so if separate would require 59 mod). The modifier indicator of "1" means ncci mod is allowed. (again if documentation proves that they are separate)
AAPC has an article in the knowledge center also:
 
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