Modifier 59 Fact Sheet
- Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.
- Documentation indicates two separate procedures performed on the same day by the same physician
- Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)
- Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits.
- Use Modifier 59 when there is NO other appropriate modifier.
- Use Modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service.
- Code combination not appearing in the NCCI edits
- Submission of E/M Codes
- Submission of weekly radiation therapy management codes (CPT 77427)
- The NCCI tables lists the procedure code pair with a modifier indicator of "0"
- Documentation does not support the separate and distinct status
- Exact same procedure code performed twice on the same day
- Multiple administration of injections of the same drug
- If a valid modifier exists to identify the services
- NCCI coding edits can be found on the CMS NCCI Coding Edits web page.
- Two physicians in the same group, with the same specialty, performing services for the same patient on the same day, are considered by Medicare to be the same physician.
Distinctly different Column 1/ Column 2 CCI Edit
Modifier reported incorrectly for CCI edit