by John Yodonise

June 1, 2014

Proper Use of Modifier 59 Graphic

Modifier 59 Misconceptions

There are many misconceptions about the proper use of Modifier 59. Medicare tracks the use of Modifier 59 and ranks practices based on their use of this modifier to select practices to audit for misuse of Modifier 59.

The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when two HCPCS/CPT codes should not be reported together either in all situations or in most situations. It is important to review this list when it changes because code combinations are added and deleted from the NCCI.

For PTP edits that have a Correct Coding Modifier Indicator (CCMI) of "0", the codes should never be reported together by the same provider for the same patient on the same date of service. For example, in Physical Therapy, the 97001 and 97750 codes should never be used together on a claim for a date of service.

For PTP edits that have a CCMI of "1", the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI associated modifiers. For example, in Physical Therapy, the 97140 and 97530 codes can be used together (the 97530 code uses the Modifier 59) as long as the services were separate and distinct on the date of service.

What Does Separate and Distinct Mean for Modifier 59?

One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are "separate and distinct". Modifier 59 is an important NCCI associated modifier that is often used incorrectly.

The term "separate and distinct" is the key to using Modifier 59. The CPT Manual definition of Modifier 59 is:

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. Documentation must support a different session, different procedure or surgery, different site or organ system. separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual.

However, when another already established modifier is appropriate, it should be used rather than Modifier 59. Only if no more descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used.

NOTE: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see Modifier 25 

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

If you are audited for misuse of Modifier 59, your documentation will be checked so it must clearly state that the criteria was met. This is very important as many of the insurance companies are closely monitoring modifiers and triggering audits when they feel the percentage of claims including the modifier are submitted by a practice or a provider.

Physical Therapy Example of Modifier 59

NCCI Column 1 Code is 97140 and NCCI Column 2 Code is 97530.

CPT Code 97140 - Manual Therapy techniques, one or more regions, each 15 minutes.

CPT Code 97530 - Therapeutic activities, direct one-on-one patient contact by the provider, each 15 minutes.

Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute intervals.

CPT code 97530 should not be reported and Modifier 59 should not be used if the two procedures are performed during the same 15 minute time interval. Normally, you will have 2 or more diagnosis codes to show that the procedures are being performed on different body parts in order to use Modifier 59 on your claim.

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