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Modifier -59

  1. Default Modifier -59
    Medical Coding Books
    Does anyone understand modifier -59? I need someone to help me understand it so that I can use it properly. Thanks

  2. Default Modifier 59
    In a neurosurgical practice there are additional level codes that you must bill multiple times. Some carriers do not allow them billed in units. That is exactly when the modifier 59 would be used. Also, modifier 59, does imply a modifier 51 on those codes that are RVU valued as primary procedures. An example is when the carrier (medicare) did not want you to put a 51 on a code (they would apply it) and you have two primary procedures done in the same operative session. Such as a 63075 and 22554. One of those codes would need a 51 and/or a 59 depending on what your carrier prefers.

    The 59 is to identify that a "distinct and seperate" procedure was done in the same operative session. It has been my experience that you don't get paid any other way unless upon appeal.

    Hope this helps.

  3. #3
    Location
    High Point, NC
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    84
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    Suppose your provider performs two "distinct & separate" procedures at the same session, but the NCCI edits bundle one into the other with an indicator of "1". You could use the 59 modifier to 'unbundle' the procedures in order to get paid for both. I tend to think of the 59 modifier as the unbundling modifier - as long as it meets all the requirements for a 'distinct & separate' procedure.

    I hope this helps.
    Cindy Gallimore, CPC, CENTC

  4. #4
    Location
    North Carolina
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    3,126
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    CMS provides a good explanation, also; as well as clinical examples...

    http://www.cms.hhs.gov/NationalCorre...modifier59.pdf

  5. Default Modifier -59
    Thanks everyone for your prompt replies. My main concern is that our billing company wants us to use Modifier -59 in our Family Practice. I just wanted to make sure that we are using it correctly. Thanks again

  6. Default Modifier -59 Denial Example
    I received a denial from our billing company because the patient had an office visit that had modifier -25 on it; yearly physical with an ekg; injections with celestone; and chest xray. They want us to add modifier -59 to the ekg and the chest x-ray. Can we do that?

  7. #7
    Location
    Columbia, MO
    Posts
    12,527
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    Quote Originally Posted by tamore View Post
    I received a denial from our billing company because the patient had an office visit that had modifier -25 on it; yearly physical with an ekg; injections with celestone; and chest xray. They want us to add modifier -59 to the ekg and the chest x-ray. Can we do that?
    My question would be why do you need to? There does not need to be any further distinction with these codes than the description the code already carries. So I would ask them why they feel it is necessary.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Location
    Lakeland, Florida
    Posts
    2
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    Beginning in 2010 CCI version 16.0 began bundling add on code 38747 with certain procedures such as 44150, etc. No one in our office has seen where we have had to use -59 modifier on an add on code before. We thought maybe it was one of the many mistakes in this first version. But when the CCI version 16.1 came out for the second quarter it still shows being bundled. We have researched this and keep coming up short of a clear answer. One time the claim is paid and the next it is denied. Has anyone else come across this issue and may have an explanation as to why this is now bundled?
    Katrina Gillin, CPC

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