The -59 modifier is used to report a "distinct procedural service". Proper use of the -59 modifier can result in payment for services that are usually denied when performed in the same case. This is because the -59 modifier unbundles the National Correct Coding Initiative edits. NCCI edits are pairs of codes created by Medicare and often also used by other payers that are not normally billed and/or payable in the same case. The NCCI edits are updated quarterly on Jan. 1, April 1, July 1 and Oct. 1st. There may be times when it is necessary to perform a procedure or service that is distinct or independent from another non-E/M service performed the same day. The NCCI edits contain pairs of codes with an indicator. If the indicate is "0" (zero) then the edit cannot be unbundled but pairs of codes with an indicator of "1" (one) can be unbundled if the service medically necessary. Because use of the -59 modifier results in payment when the service would not normally be paid, it is closely watched by payers for abuse.
The modifier -59 is appended to the procedure that is listed in the second column identifying it as a distinct and separate service not normally reported together with the primary procedure, but appropriate under the circumstances.
For example, assume the physician does a lumbar epidural (CPT 62311) and a knee injection (20610) in the same case. According to the NCCI edits, 62311 is bundled with 20610 with an indicator of "1". In this case the epidural would be listed first and the -59 modifier would be placed on the knee injection 20610--59.
In another example, let's assume that the physician does a lumbar epidural (62311) with a trigger point injection in the trapezius muscle (20552). According to the NCCI edits, 62311 is not bundled with 20552, but 20552 is bundled with 62311 with an indicator of "1". In this case trigger point injection 20552 would be listed first and the -59 modifier would be placed on the epidural injection 62311 -59.
Documentation must support the reason why a distinct procedure or surgery was necessary. There should be documentation of the different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
When another already established modifier is appropriate, it should be used rather than modifier -59. Use modifier -59 only when a more descriptive modifier is not available and the use of modifier -59 best explains the circumstances.
Also be aware that modifier -59 should not be used with an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, use modifier -25.
Since the -59 modifier overrides or unbundles the NCCI edits, it should be used only when it is justified by the clinical circumstances and the additional code can be unbundled and reported for the same date of service as a distinct and separate service per the NCCI list. Since the NCCI edits change quarterly it's a good idea to check the NCCI list first to determine if the code combination is assigned a "1" (unbundling allowed) or a "0" (not allowed). In addition not all payers follow NCCI edits so it's a good idea to check with the each payer to see if they have published coding edits. Proper use of the -59 modifier can help ensure compliance and result in appropriate payment for distinct procedural services.
Linda Van Horn, MBA, is president and CEO of 21st Century Edge, a leading edge healthcare management consulting firm that specializes in working with physician, hospitals and ASCs on the business aspects of improving pain management services. Learn more about 21st Century Edge.
The modifier -59 is appended to the procedure that is listed in the second column identifying it as a distinct and separate service not normally reported together with the primary procedure, but appropriate under the circumstances.
For example, assume the physician does a lumbar epidural (CPT 62311) and a knee injection (20610) in the same case. According to the NCCI edits, 62311 is bundled with 20610 with an indicator of "1". In this case the epidural would be listed first and the -59 modifier would be placed on the knee injection 20610--59.
In another example, let's assume that the physician does a lumbar epidural (62311) with a trigger point injection in the trapezius muscle (20552). According to the NCCI edits, 62311 is not bundled with 20552, but 20552 is bundled with 62311 with an indicator of "1". In this case trigger point injection 20552 would be listed first and the -59 modifier would be placed on the epidural injection 62311 -59.
Documentation must support the reason why a distinct procedure or surgery was necessary. There should be documentation of the different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
When another already established modifier is appropriate, it should be used rather than modifier -59. Use modifier -59 only when a more descriptive modifier is not available and the use of modifier -59 best explains the circumstances.
Also be aware that modifier -59 should not be used with an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, use modifier -25.
Since the -59 modifier overrides or unbundles the NCCI edits, it should be used only when it is justified by the clinical circumstances and the additional code can be unbundled and reported for the same date of service as a distinct and separate service per the NCCI list. Since the NCCI edits change quarterly it's a good idea to check the NCCI list first to determine if the code combination is assigned a "1" (unbundling allowed) or a "0" (not allowed). In addition not all payers follow NCCI edits so it's a good idea to check with the each payer to see if they have published coding edits. Proper use of the -59 modifier can help ensure compliance and result in appropriate payment for distinct procedural services.
Linda Van Horn, MBA, is president and CEO of 21st Century Edge, a leading edge healthcare management consulting firm that specializes in working with physician, hospitals and ASCs on the business aspects of improving pain management services. Learn more about 21st Century Edge.