Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (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.
It is the most reported modifier that affects National Correct Coding Initiative (NCCI) processing.
The Medicare NCCI includes edits that define when two HCPCS / CPT codes should not be reported together.
A correct coding modifier indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.
A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers.
CCMI of "9," NCCI editing does not apply.
This modifier may be reported to indicate that a procedure or service was distinct or independent from other services performed on the same day.
Note: Modifier 59 should not be appended to an E/M service.
Report HCPCS modifiers XE, XP, XS, and XU to provide greater reporting specificity in situations where modifier 59 was previously reported. For details on modifiers 59 and X (EPSU, please refer to the Modifiers 59 and X (EPSU).
A different session
Different procedure or surgery
Different site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
Separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
Second initial injection procedure when protocol requires two separate sites or when the patient has to come back for a separately identifiable service
Modifiers XE, XS, XP, and XU give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible. (Only use modifier 59 if no other more specific modifier is appropriate.)
CMS allows the modifiers 59 or –X{ESPU} on Column One or Column Two codes.
Evaluate other
anatomical modifiers such as the RT/LT identifying right and left, F1 - F0 to identify fingers, T1-T0 to identify toes and E1-E4 to identify eyelids, coronary arteries modifiers, LC, LD, LM, RC or RI.
When another established more descriptive modifier is available and more appropriate.
When used with an E/M service.
If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass).
To report a separate and distinct E/M service with a non-E/M service performed on the same date (refer modifier 25).
When a valid modifier exists to identify the services.
When documentation does not support the separate and distinct status.
When used to indicate multiple administration of injections of the same drug.
When the NCCI tables lists the procedure code pair with a modifier indicator of "0".
Flowchart
Evaluate other modifiers to determine whether modifier 59 is the most appropriate.
Bill all services performed on one day on the same claim.
Report each service on a separate line.
Append 59 to the subsequent procedures (if applicable).
More than one line with modifier 59 appended to the same procedure code requires submission of supporting information/documentation on the claim.
Block 19 of the paper CMS-1500 (02-12) claim form
2300 loop of the electronic equivalent
Use modifier 59 to identify procedures or services not normally reported together but is appropriate under certain clinical circumstances.
Consider reporting Modifiers XE, XS, XP, and XU which give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible.
Claims reporting modifier 59 on multiple lines for the same procedure code without a narrative or documentation to support the additional lines will receive rejection code 969/standard code 16 (Claim/service lacks information or has submission/billing error(s), needed for adjudication).
It is very important that medical records include documentation to support the use of modifier 59 (or any other modifier).
Documentation provides a clinical picture of what was done and why a modifier was appropriate. Often, the documentation received lacks evidence/clinical circumstance to substantiate its use, resulting in a denial.
Lab services
Line 1 = 88341 pay
Line 2 = 88341 59 pay
Line 3 = 88341 59 reject if supporting documentation not reported
Physical therapy services
Line 1 = 97110 GP pay
Line 2 = 97110 GP59 pay
Line 3 = 97110 GP59 reject if supporting documentation not reported
If you have documentation to support the additional lines with modifier 59, please resubmit the claim with supporting documentation in the narrative field (block 19/2300 loop).
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