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Modifier 59 Fact Sheet

Definition

  • Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.

Appropriate Usage

  • 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.

Inappropriate Usage

  • 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 listed 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

Additional Information

  • NCCI listings can be found on the CMS National Correct Coding(external link) website.
  • Medicare considers two physicians in the same group with the same specialty performing services on the same day the same physician.

Example

Distinctly different Column 1/ Column 2 CCI Edit

Modifier 59 Correctly applied

Modifier reported incorrectly for CCI edit

Modifier 59 Denied

Page Last Updated: Wednesday, 09-Oct-2013 12:57:54 CDT