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Modifier 59 with two "separate procedures"

  1. #1
    Default Modifier 59 with two "separate procedures"
    Exam Training Packages
    Always is a strong word. So, is modifier always used if you have two CPT codes that are labeled "separate procedure." Are there any exceptions?

  2. #2
    Exclamation No!
    You ONLY bill CPT's labeled (separate procedures) when they are the only thing done, or there is STRONG evidence that it is unrelated to ANY other procedure billed that day. IF medical records support biling the code separately (and that's a HUGE if), then it would require a 59 modifier to acknowledge that it's a distinct procedural service (yes, it's the 59 every time). Do NOT just tack one on to get the code paid; that could end up costing more in the end if you were audited. Please see this artice:

    https://www.cms.gov/NationalCorrectC...odifier59.pdfl
    Last edited by btadlock1; 12-12-2010 at 08:17 PM.

  3. #3
    Red face I should clarify, though...
    You would need the 59 modifier every time you bill a code labeled (separate procedure) with a more comprehensive code on the same date, even if they don't seem related, in order for the code to be accepted by commercial payer claims edit software.

    A good example is 94150 (vital capacity), with an office visit like, 99213. Vital capacity is not routinely part of the office visit, but without a 59 modifier, insurer's using McKesson's claims edit software will deny 94150. (If you have access to Cigna or BCBS's provider websites, or Availity, you can see the rationale for the denial with their claim edit tools, and you can also see that it will allow payment with a modifier.

    I forget other people don't just deal with commercial insurers specifically...sorry...Thinking in commercial-only terms is a habit I forget about having...

  4. #4
    Smile Two Separate procedures and mod 59
    Thank you, great response and article. But may I make sure that I understand you? here is the situation:

    Px#1: Separate Procedure
    Px#2: Separate Procedure with mod 59

    Is this correct? Or if not, how would you code it?

    I appreciate your patience and help.

  5. #5
    Default
    No problem...I'd have to know the specific codes, and the primary diagnosis to tell you...

  6. #6
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    Default Please post the scrubbed operative note
    When asking a question such as this it is always best to post the scrubbed operative note (i.e. remove any patient-identifiers). Just as you cannot code without seeing the actual note, we cannot give you accurate advice without actually seeing the note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. #7
    Default Modifier 59 with two "separate procedures"
    Thank you for the feedback. You are all right that it does come down the note and you need the specific codes to make the best coding decision. But I had to make a decision on this...It comes to, is mod 59 "always" used in this case? I believe the answer is no, because many times this type of case will require mod 51, which is what I used. Any feedback?

  8. #8
    Default
    See the "Separate procedure" section of the surgery guidelines in the CPT book (Green pages). It says to use a 59 modifier on "separate procedure" codes to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. The guidelines imply that anytime you bill a code with that designation with other services, you should append a 59 modifier to it.

    See this article on Modifier 51...
    http://www.medicalbillingcptmodifier...e-surgery.html

  9. #9
    Default Modifier 59 with two "separate procedures"
    But can you say, "always" a mod 59 for two separates? It is not a part of a more comprehensive px, and we have multiple procedures.

  10. #10
    Default
    This should answer your question, I believe...

    http://www.codingandcompliance.com/n...Procedures.pdf

    It's from 2004, but it's still applicable. It gives examples of when to use 51 and when to use 59.

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