Modifier 59 | Distinct Procedural Service Explained
Modifier 59 can be used for procedures or services that are not typically reported together but are appropriate in specific situations. For example, if a patient has a skin lesion removed from their arm and a separate lesion removed from their leg on the same day, modifier 59 can be used to indicate that the procedures were distinct and independent from each other. However, it is important to note that modifier 59 should only be used if there is no more appropriate modifier to explain the circumstances.
1. What is Modifier 59?
Modifier 59 describes a situation where a provider performs two or more procedures or services that are not typically reported together but are appropriate in specific situations.
It tells the payer that the same provider does not ordinarily perform one procedure with another procedure for the same patient on the same day. Therefore, the procedures would not usually be reported together.
Modifier 59 is used to identify a procedure that is distinct or independent from other non–E/M services that the provider performs on the same day.
2. When to use Modifier 59?
Modifier 59 should be used when the provider performs two or more procedures or services that are not typically reported together but are appropriate in specific situations.
To report modifier 59, the provider’s documentation must support a different encounter or session, different surgery or procedure, different organ system or body site, separate incision or excision, separate lesion, or separate injury.
Modifier 59 should only be appended if no more appropriate modifier exists to explain the circumstances. In addition, documentation must support the use of the modifier.
3. Description
The official description of modifier 59 is “distinct procedural service”.
Under certain circumstances, indicating that a procedure or service was distinct or independent from other non-E/M services performed on the same day may be necessary.
Modifier 59 is used to identify procedures/services that are not commonly reported together but are appropriate under the circumstances.
4. Examples
Examples of procedures that may require modifier 59 include a diagnostic mammogram and a screening mammogram performed on the same day, a biopsy and destruction of a lesion performed on the same day, or a colonoscopy and a sigmoidoscopy performed on the same day.
It is important to note that not all procedures can be reported with modifier 59. Therefore, it is essential to review code descriptors and NCCI code pair edits to determine when it is appropriate to use the modifier.
5. Documentation
To use modifier 59, the provider’s documentation must support a different encounter or session, different surgery or procedure, different organ system or body site, separate incision or excision, separate lesion, or separate injury.
The documentation should clearly indicate why the procedures were performed together and are distinct or independent. It is important to note that modifier 59 should be supported by the medical record and not be used to bypass bundling edits or increase reimbursement.
6. Billing
When billing with modifier 59, the modifier should be appended to the procedure code distinct or independent from other non–E/M services the provider performs on the same day.
The modifier should be placed in the first modifier field of the claim form. It is important to note that some payers may require additional documentation or information when modifier 59 is used.
7. Common Mistakes
One common mistake medical coders make when using modifier 59 is when another already established modifier is appropriate.
Review code descriptors and NCCI code pair edits to determine when it is appropriate to use modifier 59. Another common mistake is using modifier 59 to bypass bundling edits or to increase reimbursement.
The use of modifier 59 should be supported by the medical record and should not be used to bypass bundling edits or to increase reimbursement.
8. Other Modifiers Related to Modifier 59
Other modifiers related to modifier 59 include modifiers XE, XS, XP, and XU. Modifier XE is used to indicate a separate encounter, XS is used to indicate a separate structure, XP is used to indicate a separate practitioner, and XU is used to indicate a service that is distinct because it does not overlap the standard components of the leading service. These modifiers are used in specific situations and should be used when appropriate.
9. Tips
When using modifier 59, reviewing code descriptors and NCCI code pair edits is essential to determine when it is appropriate to use the modifier. The documentation should clearly indicate why the procedures were performed together and are distinct or independent.
The use of modifier 59 should be supported by the medical record and should not be used to bypass bundling edits or to increase reimbursement. It is also essential to stay up-to-date with changes in coding guidelines and payer policies related to modifier 59.
