Modifier 59 Background
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 modifier 59 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 procedural 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).
Modifier 59 instruction: The secondary, additional, or lesser procedure(s) or service(s) must be identified by adding the Modifier 59 examples.
Modifier 59 Description/Definition
The CPT Manual defines Modifier 59 as follows:
“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used.”
Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see Modifier 25.
Modifier 59 – Usage & Reimbursement
- Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
- Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day,
- Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.
Modifier 59 – Specific Appropriate Uses
- Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.
- Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
- Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.
Modifier 59 Billing 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. Modifier 59 (different substance) should be attached to the lesser valued technique indicating that separate agents were administered by different techniques.
Modifier 59 Billing 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, modifier 59 should be attached to the initial incisional hernia repair code.
Modifier 59 Should Not Be Used With The Following CPT Codes:
- CPT code 77427 – Radiation treatment management, five treatments
- CPT code 99201 – 99499 – Evaluation and management services
When a provider submits a claim for any of the codes specified above with Modifier 59, the carrier must process the claim as if the modifier were not present.