Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not at all sure when to use it. Other practices hesitantly apply it when they believe it is appropriate, and a few practices tack it on to all sorts of codes in the hopes it will result in a payment rather than a denial. This diversity in modifier usage is not surprising because Medicare’s modifier -59 directives are definitely vague.
CPT® Guidelines indicate that the modifier is to be used to show that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, a different procedure or surgery, a different site or organ system, or a separate incision/excision.
The trouble with this modifier -59 directive is that it is somewhat ambiguous, and as we work with different practices in improving their revenues and compliance, we have found that there is a wide variation in interpretation of directives. The definition refers to “different anatomic sites” and “separate patient encounters.” From an NCCI perspective, the anatomic sites include different organs or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ.
Medicare also advises that the use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosis code for each procedure. And the use of different diagnoses on the procedures does not necessarily support the use of modifier -59.
Correct use of modifier -59 is important because that modifier has the ability to over ride NCCI edits. NCCI edits define when two CPT® codes can be reported together and still be paid separately. If the NCCI edits show that two codes reported together cannot be paid separately, one of the codes will be denied – and the practice will not be paid for that service. However, when modifier-59 is attached to one of the codes, then both codes are likely to be paid. And as we are all aware, if Medicare pays us when they should not have paid us, then at some point in time they will take that money back. No one wants to pay money back, especially if we believed that we were due the money in the first place.
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