The Appropriate Usage of Modifier 59

The CPT modifier number 59 is used to describe procedures that are “separate and distinct” so that both may be billed. The modifier, however, is very frequently misused and misunderstood. Clarification is needed to understand how to appropriately bill using modifier 59.

The definition used in the CPT Manual for modifier 59 is as follows:

“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, 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. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.” 

This long and complicated description can cause confusion; incorrect usage can frequently occur as a result. So, let’s break it down and discuss when it IS okay to use modifier 59 and when it is NOT.

When To Use Modifier 59

1. Modifier 59 should be used to indicate procedures that are done at separate anatomical sites AND are not ordinarily performed or encountered on the same day. Not only do the procedures have to be on different anatomical sites, but they also must not be two procedures that are normally performed at the same time; they must be distinct from one another.
   • “Different anatomical sites” is defined by NCCI guidelines as separate organs, and in some particular cases separate lesions on the same organ.
   • Different contiguous structures in one organ does NOT constitute the use of modifier 59.
2. Modifier 59 should be used to indicate procedures performed in separate encounters on the same day. If a patient comes in once in the morning and again in the afternoon, modifier 59 can be used IF no other modifier can be used.
3. Modifier 59 should be used to indicate two procedures described by time codes that occur sequentially. One use of modifier 59 involved procedures that are described specifically by a unit of time (30 minutes, per half-hour, eg.). If two of these procedures occur non-concurrently, modifier 59 may be used.
4. Modifier 59 should be used when a diagnostic procedure is the reason for a surgical procedure or a non-surgical therapeutic procedure. If a diagnostic procedure is the basis for a therapeutic procedure, modifier 59 may be used.
5. Modifier 59 should be used when a diagnostic procedure that is not normally performed follows a surgical or non-surgical therapeutic procedure. If a diagnostic procedure follows a therapeutic procedure and is not a common, necessary, or expected follow-up to the therapeutic procedure that was performed.

When NOT To Use Modifier 59

1. Modifier 59 should NOT be used when there is another CPT modifier that better described the relationship. Modifier 59 should be used as a “last resort.” If one of the other NCCI-related CPT modifiers (24, 25, 27, 57, 58, 78, 79, or 91) better describes the relationship, it should always be used instead of modifier 59.
2. Modifier 59 should NOT be used to bypass a PTP edit unless specific guidelines have been met. A more obvious rule, if the guidelines for modifier 59 have not been met, modifier 59 can not be used to bypass a PTP edit.
3. Modifier 59 should NOT be used when the basis of the use is due to the fact that the pair edits are “different procedures.” A frequent misuse of modifier 59 involves a code pair edit that has two separate procedures. Because the procedures can be seen as “separate and distinct”, the modifier is frequently used incorrectly here. The NCCI edit indicates, however, that these two codes should not be listed together, and so modifier 59 should not be used.

If you would like to learn more about modifier 59 and other modifiers and rules, please contact Zenith Healthcare Solutions for coding assistance.

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