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00731  Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified ...

Modifier 59 Distinct Procedural Service


Definition: The “-59” modifier is used to indicate a distinct procedural service. The physician may need to indicate 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, different procedure or surgery, different site, or organ system, separate incision/excision, or separate injury (or area of injury in extensive injuries).

Rationale: Multiple services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because these circumstances cannot be easily identified, a modifier was established to permit claims of such a nature to bypass correct coding edits. The addition of this modifier to a procedure code indicates that the procedure represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different surgery, different anatomical site or organ system, separate incision/excision, different agent, different lesion, or different injury or area of injury (in extensive injuries).

Instruction: The secondary, additional, or lesser procedure(s) or service(s) must be identified by adding the modifier “-59”.

Following are examples of appropriate use of the “-59” modifier:

EXAMPLE 1:

CPT codes describing chemotherapy administration include codes for the administration of chemotherapeutic agents by multiple routes, the most common being the intravenous route. For a given agent, only one intravenous route (push or infusion) is appropriate at a given session. It is recognized that frequently combination chemotherapy is provided by different routes at the same session. When this is the case, using the CPT codes 96408, 96410, and 96414, the “-59” modifier (different substance) should be attached to the lesser valued technique indicating that separate agents were administered by different techniques.

EXAMPLE 2:

When a recurrent incisional or ventral hernia requires repair, the appropriate recurrent incisional or ventral hernia repair code is billed. A code for initial incisional hernia repair is not billed in addition to the recurrent incisional or ventral hernia repair unless a medically necessary initial incisional hernia repair is performed at a different site. In this case, the “-59” modifier should be attached to the initial incisional hernia repair code.

Modifier “-59” should not be used with the following codes:

77427 Radiation treatment management, five treatments

99201 - 99499 Evaluation and management services

When a provider submits a claim for any of the codes specified above with the “-59” modifier, the carrier must process the claim as if the modifier were not present.

Please follow the below links for Appropriate usage of Modifier 59 with more Examples

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf

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