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modifier 59 and medicare

  1. Default modifier 59 and medicare
    Medical Coding Books
    It has always been my understanding that you only use mod-59 when procedures are bundled or, of course, when at different sites, etc (as per definition). As such, when coding a surgery for Medicare, I only added the mod-59 if I had two procedures showing as bundled. If the surgeon did two things at once, and the codes were NOT bundled, I did not add any modifier. Since Medicare doesn't accept 51 (which would be most appropriate) and the codes aren't bundled. However, I was told today by someone that since Medicare doesn't accept 51, even tho the codes are NOT bundled you still have to use a mod-59 for multiple procedures. I think this is incorrect but can't seem to find anything to back me up. Anyone have the answer and a place for reference??? I would appreciate your help!

  2. #2
    North Carolina
    Unless you find a carrier that is very specific in their policy, you may find that this "existing policy" is a theory until a denial arrives. I can tell you from experience that (i.e. spinal surgery) when we do multiple levels, the exempt, modifier 51 "add-on" codes often get denied as a duplicate. Only when we appeal with an explanation of adding modifier 59 *and* the op note, do they process for payment. Fair?...NO...common?...Yes...
    Last edited by RebeccaWoodward*; 08-15-2011 at 05:09 PM.
    Rebecca CPC, CPMA, CEMC

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  3. Default
    It sounds like it depends on who your Medicare carrier is. In Pennsylvania we use modifier 51 and do not have any problems. We also bill for spinal surgery and do not have any problems with our add on codes being paid correctly. I would suggest going to your Medicare carrier's website and see what they say about modifiers or call customer service and ask them.

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