Some billers do not really understand modifiers or when they need to use them. Add modifiers to CPT codes when they are required to more accurately describe a medical procedure or service.
A modifier should never be used just to get higher reimbursement or to get paid for a procedure that will otherwise be bundled with another code.
But modifiers can be tricky. Many times providers inappropriately use them, and abuse which inevitably leads to claim denials. In this post, we’ll focus on the trickiest of them all, the 59 modifier.
According to the CMS Medical Learning Network, the 59 modifier is:
* Infrequently (and usually correctly) used to identify a separate encounter;
* Less commonly (and less correctly) used to define a separate anatomic site; and
* More commonly (and frequently incorrectly) used to define a distinct service.
When to Use Modifier 59
To decrease misuse and promote greater specificity, CMS essentially broke the 59 modifier into 4 more distinct ‘x codes’ that describe:
* Separate encounter
* Separate organ or structure
* Separate practitioner
* ‘Unusual, non-overlapping service’
For more details on these changes, see the CareCloud blog post ‘The End of Modifier 59?”
CMS reports they will still recognize the 59 Modifier, at least initially, except in cases where a more descriptive X code is appropriate.
The 59 modifier should only be added by the provider or by a coder who has access to the patient’s chart. If you are the biller and you believe that the modifier 59 would be appropriate but was not indicated, you should go back to see if the provider omitted it by mistake.
59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed, use it instead of modifier 59.
59 Modifier Examples
An example of the 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 CMS considers these procedures inclusive.
If the 59 modifier is appended to either code, they will both be allowed on the claim separately. However, the 59 modifier should only be added if the performance of the two procedures took place in distinctly separate 15 minute intervals. If the therapist performs the procedures simultaneously, do not use the 59 modifier.
Another example would be if the patient were having a nerve conduction study with CPT billed with codes 95900 and 95903. If the two procedures treat separate nerves, then the 59 modifier should be added. In contrast, two simultaneous treatments on the same nerve would void the use of modifier 59.
When using the 59 modifier to indicate a distinct and separate service, documentation should be in the patient’s medical file that substantiates that the services were performed separately. The insurance carrier may ask to review the record to decide on appropriate use before reimbursing the full amount for the modified CPT code.
Misusing 59, or any other modifier, can cause a payer to deny your claim altogether. Avoid claim issues by making sure to always use it properly.
Alice Scott and Michele Redmond contributed to this post.
More accurate? More complex? Both? Or something else? What do you think of CMS’ changes to the 59 Modifier? Leave your perspective below.
