Modifier 59

Modifier 59 Description, Uses, Guidelines & Examples (2022)

Modifier 59 indicates the distinct procedural service performed by the physician on the day with other procedures and services. 

Modifier 59 Description

Modifier 59 indicates the distinct procedural service performed by the physician on the day with other procedures and services. In addition, modifiers 59 divides into four categories, such as XU, XE, XS, and XP, to further specify services for Medicare insurance. 

It may represent the service such as distinct organ and structure, separate session and encounter, different surgery or procedure, separate injury, or separate lesions/incision/excision, which the same physician does not typically perform on the same day.  

The following are the usage modifier XU, XE, XP, or XS instead modifier 59:

Modifier XU may use instead of modifiers 59 when an unusual non-overlapping service performs by the physician, but it does not overlap the main components of the procedure or service.

Modifier XP may use instead of modifier 59 when service performs by the distinct practitioner on the same day as other practitioners.

Modifier XS may use instead of 59 Modifier when service performs by the physician on a distinct structure or organ on the same day.

Modifier XS may use instead of 59 when service performs by the physician to indicate the different encounters on the same day.

Modifier 59 does not include evaluation and management codes (99202-99499). Therefore, it is appropriate to attach modifier 25 with E/M codes when a particular service performs with the other procedure and service.

Radiology CPT codes are most frequently billed with 59 Modifier to indicate the different or overlapping service performed on the same day to unbundle the procedure and reimbursement from the insurance. Modifiers 76 and 77 are appropriate instead of modifiers 59 when service performs by the same or different physician on the same day to the same patient. 

Modifier 59 only applies with procedure codes when no other modifier is appropriate to report with that service. Therefore, it is not relevant to bill 59 instead of the established modifier.

CMS defines rules such as NCCI when the modifier is appropriate with the other procedure or not Procedure-to-Procedure (PTP) edits. For example, if the Correct Coding Modifier Indicator (CCMI) is ”0”, services are not allowed to be billed together on the same day in addition to other services. Therefore, adding 59 with the procedure and service is appropriate.

If the Correct Coding Modifier Indicator (CCMI) is ”1”, procedures are allowed to be billed together on the same day in addition to other services. Adding appropriate modifiers such as 59 with the CPT code and service is appropriate.

modifiers 59

What Is Modifier 59?

Modifier 59 append with the service when two procedures or services are generally not billed together or performed on a particular site or anatomical location on the same day. It represents the service performed on a different anatomical site, organ structure, or incision site and is separately reportable in addition to the other service. 

When To Use Modifier 59

Modifier 59 attaches with the CPT codes when no other appropriate modifier is available to unbundle the services or procedure performed by the physician on the same day. If the modifier is known to represent the service more accurately, it is relevant to bill with that modifier instead of 59.

59 Modifier bills more frequently or misused than the other modifiers. It typically represents the two services performed during the same visit but different anatomical location sites, organs, or structures on the human body.

It frequently attaches with CPT codes to unbundle the services or procedures performed on the same day by the physician on a similar claim. Therefore, it is not appropriate to report always 59 with the services to bypass the NCCI edit. Instead, it adds an established modifier instead of 59 when the fit is relevant.

Medical documentation and patients condition should support the service as a distinct or a separate service when adding the 59 with the services and the procedures. The insurance carrier may review the claims if 59 correctly appends the services and practices for proper reimbursement or payment reduction.

Modifiers 59 does not require the same diagnosis codes for each service. Different diagnosis codes do not deem the medical necessity of service or procedure until it is genuinely a distinct and separate service.

Modifier 59 Guidelines

Modifier 59 applies procedure codes to report the separate service on different anatomical sites and locations.

59 is only applicable when no other appropriate modifier is available to attach with procedure codes on the claim. 

59 Modifier does not apply when CPT code descriptors are different. For example, it is inappropriate to append 59 when NCCI does not allow the surgery or procedures on the same day by the Same Physician on the same anatomical sites. In some circumstances, NCCI allows bill 59 with CPT codes to bypass the edit on the exact anatomical location in the same encounter.

HCPCS modifiers XS, XP, XE, or XU instead of Modifiers 59 are appropriate when the service bills to the medicare insurance carrier to specify the procedure or service if it is distinct or separate. 

Modifier 51 vs 59

Modifiers 59 and 51 indicate multiple procedures and services performed on the same day in a single encounter but for different intents. 

Modifier 51 applies to the service when different procedures furnish in the same session. For example, a single operation is performed multiple times at various sites, or a single operation performs numerous times at the exact location.

Attaching modifier 51 with the procedure, evaluation, and management CPT codes when performed is irrelevant. However, it may influence the payment of the service and make reductions with other procedures performed on the same day. It is significant to report high-dollar claims first to get higher prices from the insurance carrier.

In Contrast, Modifier 59 applies to the services performed in a different session or encounter on the same day. This procedure is distinct from the other service, anatomical site, separate incision, excision, injury, or body location. 

Attaching 59 with the procedure when performing, evaluating, and managing CPT codes is also irrelevant. It is not appropriate to the bill when an established modifier is available. 

Modifier 25 vs 59

Modifier 25 applies with Evaluation and management codes (99202-99499) only and indicates the service is a significant identifiable service performed by the Same Physician on the same day. 

In contrast, Modifier 59 indicates the service is distinctly other than the evaluation management CPT codes (99202-99499) on the same day by the same physician. It reports when typically two services are not allowed to bill together on the same day. Documentation should support that the service is medically appropriate and distinct.

Modifier 76 vs 59

Modifier 76 applies with service when the same physician performs a similar service or procedure on the same day to the same patient in combination with the other service.

In contrast, Modifier 59 represents the particular service performed by the physician on the same day and is usually not allowed to be billed together on the same day. 

96372 Modifier 59

If Administration vaccines/toxoids (90460-90461, 90471-90472, 0001A, 0002A, 0003A, 0004A, 0051A, 0052A, 0053A, 0054A, 0071A, 0072A, 0011A, 0012A, 0013A, 0064A, 0021A, 0022A, 0031A], 0034A, 0041A, 0042A) performs in combination with CPT code 96372, It is appropriate to report CPT 96372 with 59 Modifier. 

If Allergen immunotherapy injections (95115-95117) ]) performs in combination with CPT code 96372, it is appropriate to report CPT 96372 with 59. 

If Antineoplastic hormonal injections (96402) performs by the physician in combination with CPT code 96372, it is appropriate to report CPT 96372 with modifier 59. 

If Antineoplastic hormonal injections (96402) performs by the physician in combination with CPT code 96372, it is appropriate to report CPT 96372 with 59.

If the physician performs antineoplastic non-hormonal injections (96401) in combination with CPT code 96372, it is appropriate to report CPT 96372 with 59 Modifier.

Suppose Injections are administered without direct supervision by a physician or other qualified health care provider (99211) performed by the physician in combination with CPT code 96372. Only CPT 96372 reports for the services because of the higher payment. In that case, it is inappropriate to report CPT 96372 with 59.

If Intra-dermal cancer immune therapy (0708T-0709T) performs in combination with CPT code 96372, it is appropriate to report CPT 96372 with modifiers 59. 

CPT Code 93306 With Modifier 59

If transthoracic without spectral and color doppler (93307) performs in combination with CPT code 93306, it is inappropriate to report CPT 93307 with modifier 59. Only CPT 93306 bills because of the higher payment.

CPT Code 97124 Modifier 59

If Myofascial release (97140) performs in combination with CPT code 97124, it is inappropriate to report CPT 97140 with 59. Only CPT97124 bills because of the higher payment.

If Electromyography (95860-95872 [95885, 95886, 95887]) performs in combination with CPT code 97124, It is appropriate to report without modifier 59.

If EMG biofeedback training (90901) performs in combination with CPT code 97124, It is appropriate to report without 59 Modifier.

If Muscle and motion range tests ([97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172]) performs in combination with CPT code 97124, It is appropriate to report without modifier 59.

If Nerve conduction studies (95905-95913) perform in combination with CPT code 97124, It is appropriate to report without modifiers 59.

97112 Modifier 59

If Electromyography (95860-95872 [95885, 95886, 95887]) performs in combination with CPT code 97112, It is appropriate to report without modifier 59.

If EMG biofeedback training (90901) performs in combination with CPT code 97112, It is appropriate to report without modifier 59.

If Muscle and motion range tests ([97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172]) performs in combination with CPT code 97112, It is appropriate to report without modifier 59.

If Nerve conduction studies (95905-95913) perform in combination with CPT code 97112, It is appropriate to report without 59.

97140 Modifier 59

If Myofascial release (97140) performs in combination with CPT code 97124, it is inappropriate to report CPT 97140 with modifier 59. Only CPT 97124 bills because of the higher payment.

If Electromyography (95860-95872 [95885, 95886, 95887]) performs in combination with CPT code 97140, It is appropriate to report without modifier 59.

If EMG biofeedback training (90901) performs in combination with CPT code 97140, It is appropriate to report without 59 Modifier.

If Muscle and motion range tests ([97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172]) ) performs in combination with CPT code 97140, It is appropriate to report without modifier 59.

If Nerve conduction studies (95905-95913) perform in combination with CPT code 97140, It is appropriate to report without modifiers 59.

CPT Code 96375 With Modifier 59

CPT 963675 is an add-on and bill in addition to the primary procedure codes such as 96365, 96374, 96409, or 96413. A maximum of 6 units of CPT 96375 can be a bill on the same day, and it is inappropriate to report modifier 59 with the first unit. Each subsequent unit of CPT 96375 reports with 59. Modifier 51 is exempt from this procedure code.

How To Avoid Denials For Modifier 59

Because claims are processed without the physician’s documentation, payers rely on the information sent to them to be accurate and assume there is documentation backing it up. Unfortunately, modifier 59 gets misused a lot.

As a result, some payers now automatically deny CPT codes appended with 59 Modifier.  This forces the provider to appeal the denial and send in the documentation to show that modifiers 59 was applied correctly.

This denial and appeal process is costly for both the provider and the payer — it delays payment and forces the provider’s staff to write appeals and the payer’s staff to read documentation and process appeals.

X Modifiers That Have Replaced Modifier 59

The Centers for Medicare & Medicaid Services (CMS) created four modifiers, referred to as X[ESPU] Modifiers, to better differentiate between the reasons for unbundling codes,

The X modifiers apply to Medicare Part B. Some commercial insurance companies have indicated in their online reimbursement manuals they will process the X[ESPU] modifiers, as well, such as Horizon Blue Cross Blue Shield of New Jersey.

CMS does not require providers to use modifiers X[ESPU] in place of modifier 59, and they continue to accept modifier 59, for now.

However, if your practice ignores the modifiers which carry more specific information and uses modifier 59 instead, do not be surprised if your Part B carrier audits your 59 usage to make sure it’s not being over-utilized to unbundle CPT codes.

Be sure to review the documentation and ask yourself if the unbundling is justified enough to apply the appropriate X[ESPU] modifier.

Modifier 59 Examples

The following are the examples of when modifier 59 appends with the CPT codes:

Example 1

A 36-year-old male presents to the physician for a Tangential biopsy of skin and destruction procedure via laser surgery. Suppose CPT codes 11102 and 17000 bills for these services. According to NCCI, these CPT codes are generally not billed together on the same day, but a modifier is allowed with these CPT codes.

If the physician performs the procedure on the same sites and anatomical modifier LT or RT is not applicable for these services, It is appropriate to report CPT code 17000 with modifier 59. In contrast, If they perform on the two distinct sides of the body or locations, It is pertinent to report both these codes with laterality modifier LT or RT instead of modifiers 59.

59 is only allowed for these services when these services perform in two distinct locations on the same day in a single encounter. It requires separate time and efforts made by the physician. 

59 Modifier appends with CPT code 17000 to unbundle the service with the CPT code 11102. It would be billed 11102 as primary procedure code and 17000 as secondary procedure code with 59. 

Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer.

Example 2

A 46-year-old male presents to the physician for laparoscopic ablation of liver tumor and Ultrasonic guidance for needle placement. Suppose CPT codes 47370 and 76942 bills for these services. A modifier is allowed with these CPT codes. According to NCCI, these CPT codes are generally not billed together on the same day.

Modifier 59 is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

59 appends with CPT code 76942 to unbundle the service with CPT code 47370 when US guidance does not apply for needle placement of tumor ablation. If US guidance for needle placement of tumor ablation, It is not appropriate to report with modifiers 59. Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer.

Example 3

A 76-year-old male presents to the physician for – Combined right and left heart catheterization and Fluoroscopy for 15 minutes. Suppose CPT codes 93453 and 76000 bills for these services. A modifier is allowed with these CPT codes. According to NCCI, these CPT codes are generally not billed together on the same day.

Modifier 59 is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

Suppose fluoroscopy guidance performs Combined right and left heart catheterization. It is not appropriate to report with 59. Instead, modifiers 59 appends with CPT code 76000 to unbundle the service with the CPT code 93453 when Fluoroscopy does not apply for Combined right and left heart catheterization. 

Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer.

Example 4

A 56-year-old male presents to the Physician for Paring or cutting of benign hyperkeratotic lesion and – Debridement of the nail. Suppose CPT codes 11055 and 11720bills for these services. A modifier is allowed with these CPT codes. According to NCCI, these CPT codes are generally not billed together on the same day.

59 Modifier is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

Modifier 59 appends with CPT code 11720 to unbundle the service with the CPT code 11055 when the Debridement of the nail does not perform on the distinct region instead of the same distal interphalangeal joint. If the Debridement of the nail serves on the same toe, It is not appropriate to report with modifiers 59. 

Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer.

Example 5

A 76-year-old male presents to the physician Destruction of a localized lesion of the retina. And he also had the Destruction of a localized lesion of the choroid. 

Suppose CPT codes 67210 and 67220 bills for these services. According to NCCI, these CPT codes are generally not billed together on the same day, but a modifier is allowed with these CPT codes.

59 Modifier is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

Modifier 59 appends with CPT code 67220 to unbundle the service with the CPT code 67210 when the Destruction of localized lesion of the choroid does not perform in the same session as the Destruction of localized lesion of the retina. If Destruction of localized lesion of the choroid in the same session, It is not appropriate to report with modifiers 59. Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer

Example 6

A 76-year-old male presents to the physician for an Arthroscopy of the shoulder with rotator cuff repair. And also, he had an Arthroscopy of the shoulder with synovectomy, partial.

 Suppose CPT codes 29827 and 29820 bills for these services. According to NCCI, these CPT codes are generally not billed together on the same day. Therefore, a modifier is allowed with these CPT codes.

59 Modifier is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

Modifier 59 appends with CPT code 29820 to unbundle the service with the CPT code 29827 when Arthroscopy of the shoulder with synovectomy does not perform in the same session. Suppose an Arthroscopy of the shoulder with synovectomy performs in the same session. It is not appropriate to report with modifiers 59. Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer

Example 7

A 48-year-old male presents to the physician Cardiovascular stress test and ECG with 1-3 Leads. Suppose CPT codes 93015 and 93040 bills for these services. According to NCCI, these CPT codes are generally not billed together on the same day. Therefore, a modifier is allowed with these CPT codes.

59 Modifier is only allowed for these services when these services perform for two distinct purposes but not for tumor ablation only. It requires separate time and efforts made by the physician. 

Modifier 59 appends with CPT code 93040 to unbundle the service with the CPT code 93015 when ECG with 1-3 Leads does not perform in the same encounter. When ECG with 1-3 Leads performs in the same visit, It is not appropriate to report with modifiers 59. Documentation must support the medical necessity of these two services on the same day for accurate reimbursement by the insurance or third-party payer

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