When should a 59 modifier be used?
Modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury. It should also be used when an intravenous (IV) protocol calls for two separate IV sites.
What does 59 modifier mean for Medicare?
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.
Which procedure gets the 59 modifier?
For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury.
What does CPT code modifier 59 mean?
Distinct Procedural ServiceModifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
Can you put a 59 modifier on an add on code?
Appropriate Uses: (Only use modifier 59 if no other more specific modifier is appropriate.) CMS allows the modifiers 59 or –X{ESPU} on Column One or Column Two codes (see the related transmittal at CR11168).Jul 26, 2021
How does modifier 59 affect reimbursement?
Modifier 59 allows you to unbundle — separately report and get paid for — two or more procedures occurring during the same encounter by the same physician that would not normally be paid independently. Use modifier 59 correctly, and you'll collect every penny of reimbursement for the work you do.Jul 29, 2019
What is an example of modifier 59?
59 Modifier Examples An example of appropriate use of the 59 modifier might be if a physical therapist performed both 97140 (manual therapy) and 97530 (therapeutic activity) in the same visit. Normally these procedures are considered inclusive.
Which modifier comes first 51 or 59?
Never use both modifier 51 and 59 on a single procedure code. If there is a second location procedure (such as a HCPCS code for right or left), use the CPT® modifier first.Feb 15, 2022
Is 59 a pricing modifier?
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.Aug 18, 2021
What is modifier 59?
Modifier 59 is used to define a “Distinct Procedural Service.”. These are procedures and services performed by a healthcare provider that are not typically reported together, but are appropriate and separately billable given the circumstances.
What modifiers are used in lieu of 59?
Medicare recently announced they’ve established four new modifiers – XE, XS, XP, and XU – that may be used in lieu of modifier 59. The codes are more specific and become effective January 1, 2015.
Is 59 a valid modifier?
How to Use the –X {EPSU} Modifiers. Modifier 59 is not going away and will continue to be a valid modifier, according to Medicare. However, modifier 59 should NOT be used when a more appropriate modifier, like a XE, XP, XS or XU modifier, is available. Certain codes that are prone to incorrect billing may also require one of the new modifiers.
What is CPT modifier 59?
The primary purpose of CPT modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It is usually used when no other modifier more appropriately describes the relationship of the procedure codes.
What is NCCI in Medicare?
The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits and they are very helpful in some particular situation. These edits define when two Healthcare Common Procedure Coding System (HCPCS) should not be reported together either in all situations or in most situations.
Is modifier 59 appropriate for E/M?
Under most circumstances, CPT modifier 59 is not appropriate for use with E/M or surgical procedure codes. One exception is multiple facet joint injections. An inappropriate use of Modifier 59 is when the narrative description of the two codes is different. One of the common misuses of modifier 59 is related to the portion of the definition ...
Does CPT modifier 59 include contiguous structures?
It does not include treatment of contiguous structures of the same organ. No special documentation is required with the claim when CPT modifier 59 is submitted. When another modifier is appropriate, it should be used rather than CPT modifier 59.
Why is Medicare 59 modifier used?
Medicare was concerned that providers was submitting the 59 modifier too often, just adding it when they felt they did not like the fact that two codes were bundled, and used the 59 modifier to get the two codes unbundled and paid. So, as of last year, Medicare decided that they would force the coding and billing operations to define why the 59 modifier is being used, so that the provider is making sure that one of the applicable reasons for using a 59 modifier was applicable to the case and is documented. So, Medicare created the following modifiers to replace the 59 modifier for Part B claims only:
What is modifier 59?
But at the same time, it is a two-edged sword, the modifier 59 is exceptionally dangerous when used incorrectly and care is not applied, just like a doctor would find for their patient when using prednisone.#N#Modifier 59 is the universal unbundling modifier. When used on a claim line, it unbundles two procedures that normally would be bundled and not paid together. Modifier 59 is telling the payer that this situation is an exception and although these two codes are normally bundled, there exists a special situation that you should consider which makes these two codes which normally are bundled, separately payable.
Why is modifier 59 important?
The Modifier 59 provides extra information so that the claim should get processed correctly because of the claim submitter’s special circumstances without the claim processor having to read the notes.
Does Medicare use modifier 59?
So, for Part B Medicare expects you to have reviewed the documentation and determined the reason for using the unbundling modifier and assign a reason to select the correct Part B Medicare modifier. The process is not different when using modifier 59 even though a specific modifier does not have to be defined because the reason ...
Four New Modifiers to Use Instead of Modifier 59 – Xe, XS, XP & Xu
What Is Modifier 59?
- Modifier 59 is used to define a “Distinct Procedural Service.” These are procedures and services performed by a healthcare provider that are not typically reported together, but are appropriate and separately billable given the circumstances. When modifier 59 is appended to a CPT code, it indicates that the service is separate and distinct from ano...
Why New Modifiers?
- Modifier 59 is not only the most used modifier, but it’s also the most abused. And while the abuse may be unintentional at times, the improper coding leads to incorrectly paid claims. As audits have increased, CMS has realized that more specific modifiers may be helpful in deterring this abuse. The -X{EPSU} modifiers are essentially a subset of modifier 59. CMS believes their usag…
How to Use The –X{EPSU} Modifiers
- Modifier 59 is not going away and will continue to be a valid modifier, according to Medicare. However, modifier 59 should NOTbe used when a more appropriate modifier, like a XE, XP, XS or XU modifier, is available. Certain codes that are prone to incorrect billing may also require one of the new modifiers. CMS is encouraging providers to adopt the modifiers quickly; they may be us…
Additional Information
- Medicare Learning Network: MLM MM8863 Manual System: Transmittal 1422 Here is a link to my other post with some examples of how to use the new modifiers. CLICK FOR MODIFIER EXAMPLES Still confused? Feel free to ask questions in the comments and we’ll do our best to answer!