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Thread: Modifier 51 Versus Modifier 59

  1. #1

    Exclamation Modifier 51 Versus Modifier 59

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    My billing company is insisting that my office no longer use modifier 51 and to append modifier 59 in place of. I feel this is incorrect but how should they bill multiple procedures if the insurances are not allowing the 51 any longer. This is in Delaware. Any advice would be appreciated.

  2. #2
    Join Date
    Apr 2007
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    Minneapolis
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    I don't agree that the 59 modifier replaces the 51 modifier but a lot of insurance companies treat the 51 modifier as informational only. It used to be used to designate which procedures received the multiple procedure reduction but payers go by the Medicare Physician Fee Schedule now so don't rely on the physicians to provide that information any more.

    The 59 modifier designates that a procedure is separate and independent from another procedure billed and relates to CCI edits. It should only be used if there is no other applicable or appropriate modifier that could be used instead.

    Is it that insurances aren't allowing it anymore or is it just unnecessary? I don't know what it hurts to use it if they just aren't recognizing it. I also wouldn't just substitute the 59 across the board because that could raise some red flags (as well as possibly being inappropriate in a lot of cases). I'd check into it further.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  3. #3
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    Apr 2007
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    Albany, New York
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    Totally wrong!

    Have they looked at the descriptions of those two modifiers in the CPT book?
    Are they aware that this may send up a red flag to Medicare (and possibly OIG??).
    Modifier 59 is only to be used if there is no other modifier that better describes a "separately distinct" non-E/M procedure that has been performed.
    That has nothing to do with "multiple procedures" being done.
    I would consider looking for another billing company......
    Karen Maloney, CPC
    Data Quality Specialist

  4. #4
    Join Date
    Apr 2007
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    Columbia, MO
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    Well said Karen! I totally agree, I provided consulting service with a billing company that also thought and taught their coders that the 51 and the 59 were one in the same, what a pain that was to re teach! Many commercial carriers have dropped the 51 from their electronic edits because they did feel it was unnecessary, so it is not that they do not recognize it, it is just not adjudicated properly in the electronic edits. But as karen stated this is not a substitute across the board for the 59, they never did communicate the same information. Good Luck with this, what you want now is to hire an auditor to audit your billing service, you may be very unpleasantly surprised at what you learn!

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