Modifier 59

Modifier -59: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that aprocedure or service was distinct or independent from otherservices performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reportedtogether, but are appropriate under the circumstances. Thismay represent a different session or patient encounter,different procedure or surgery, different site or organsystem, separate incision/excision, separate lesion, orseparate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day bythe same physician. However, when another alreadyestablished modifier is appropriate, it should be usedrather than modifier 59. Only if no more descriptivemodifier is available, and the use of modifier 59 bestexplains the circumstances, should modifier 59 be used." Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purposeis to indicate that two or more procedures are performed atdifferent anatomic sites or different patient encounters.It should only be used if no other modifier moreappropriately describes the relationships of the two ormore procedure codes. NCCI edits define when two procedure HCPCS/CPT codes maynot be reported together except under specialcircumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported togetherif the two procedures are performed at different anatomicsites or different patient encounters. Carrier processingsystems utilize NCCI-associated modifiers to allow paymentof both codes of an edit. Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCIedit unless the proper criteria for use of the modifier ismet. Documentation in the medical record must satisfy thecriteria required by any NCCI-associated modifier used. One of the misuses of modifier –59 is related to the portion of the definition of modifier -59 allowing its useto describe “different procedure or surgery”. The code descriptors of the two codes of a code pair edit usuallyrepresent different procedures or surgeries. The edit

indicates that the two procedures/surgeries cannot bereported together if performed at the same anatomic siteand same patient encounter. The provider cannot usemodifier –59 for such an edit based on the two codes beingdifferent procedures/surgeries. However, if the twoprocedures/surgeries are performed at separate anatomicsites or at separate patient encounters on the same date ofservice, modifier –59 may be appended to indicate that theyare different procedures/surgeries on that date of service. Use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosisfor each HCPCS/CPT coded procedure/surgery. Additionally,different diagnoses are not adequate criteria for use ofmodifier -59. The HCPCS/CPT codes remain bundled unlessthe procedures/surgeries are performed at differentanatomic sites or separate patient encounters. From an NCCI perspective, the definition of differentanatomic sites includes different organs or differentlesions in the same organ. However, it does not includetreatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent softtissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitute a singleanatomic site.