Using Modifier 59 or Modifier 76
Wisconsin Physician Services (WPS) Medicare has a large number of claims denying for incorrect Modifier 59 usage. WPS Medicare researched these denied claims and found that Modifier 76 would be the appropriate modifier to use for several of the denials.
In an effort to help providers determine appropriate modifier usages, WPS Medicare has developed a series of Modifier Fact Sheets.
Modifier 59Modifier 59 is defined as "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 Correct Coding Initiative (CCI) edits
- Use Modifier 59 when there is NO other appropriate modifier
- Code combination not appearing in the CCI edits
- Submission of Evaluation & Management (E/M) Codes
- Submission of weekly radiation therapy management codes (CPT 77427)
- Medicare Physician Fee Schedule Database (MPFSDB) lists the procedure code with a modifier indicator of "0"
- Documentation does not support the separate and distinct status
- The exact same procedure code was performed twice on the same day
- If a valid modifier exists to identify the services
- CCI listings can be found on the
CMS National Correct Coding website.
- Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.
Modifier 76 represents a repeat procedure by the same physician and indicates when it is necessary to report a procedure repeated subsequent to the original procedure.
- On a procedure code that cannot be quantity billed
- When reporting each service on a separate line, using a quantity of one and appending 76 to the subsequent procedures
- When the same physician performs the services
- Appending to a surgical procedure code
- Appending to each line of service
- Repeat services due to equipment or other technical failure
- For services repeated for quality control purposes
- Medicare considers two physicians in the same group with the same specialty performing services on the same day the same physician
- For all procedure codes that cannot be quantity billed, always use a quantity of "1"
- To avoid denials please bill all services performed on one day on the same claim
- For repeat clinical diagnostic laboratory test, use modifier 91 if the service can not be quantity billed.