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Health and Human Services: modifier59

Health and Human Services: modifier59



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Published by: HHS on Jan 30, 2008
Copyright:Attribution Non-commercial


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CPT Manual
defines modifier -59 as follows:
 Modifier -59:
Distinct Procedural Service:
Under certaincircumstances, the physician may need to indicate that aprocedure or service was distinct or independent from otherservices performed on the same day. Modifier 59 is used toidentify procedures/services that are not normally reportedtogether, but are appropriate under the circumstances. Thismay represent a different session or patient encounter,different procedure or surgery, different site or organsystem, separate incision/excision, separate lesion, orseparate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day bythe same physician. However, when another alreadyestablished modifier is appropriate, it should be usedrather than modifier 59. Only if no more descriptivemodifier is available, and the use of modifier 59 bestexplains the circumstances, should modifier 59 be used."Modifier -59
is an important NCCI-associated modifier thatis often used incorrectly. For the NCCI its primary purposeis to indicate that two or more procedures are performed atdifferent anatomic sites or different patient encounters.It should only be used if no other modifier moreappropriately describes the relationships of the two ormore procedure codes.NCCI edits define when two procedure HCPCS/CPT codes maynot be reported together except under specialcircumstances. If an edit allows use of NCCI-associatedmodifiers, the two procedure codes may be reported togetherif the two procedures are performed at different anatomicsites or different patient encounters. Carrier processingsystems utilize NCCI-associated modifiers to allow paymentof both codes of an edit. Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCIedit unless the proper criteria for use of the modifier ismet. Documentation in the medical record must satisfy thecriteria required by any NCCI-associated modifier used.One of the misuses of modifier –59 is related to theportion of the definition of modifier -59 allowing its useto describe “different procedure or surgery”. The codedescriptors of the two codes of a code pair edit usuallyrepresent different procedures or surgeries. The
indicates that the two procedures/surgeries cannot bereported together if performed at the same anatomic siteand same patient encounter. The provider cannot usemodifier –59 for such an edit based on the two codes beingdifferent procedures/surgeries. However, if the twoprocedures/surgeries are performed at separate anatomicsites or at separate patient encounters on the same date ofservice, modifier –59 may be appended to indicate that theyare different procedures/surgeries on that date of service.Use of modifier -59 to indicate differentprocedures/surgeries does not require a different diagnosisfor each HCPCS/CPT coded procedure/surgery. Additionally,different diagnoses are not adequate criteria for use ofmodifier -59. The HCPCS/CPT codes remain bundled unlessthe procedures/surgeries are performed at differentanatomic sites or separate patient encounters.From an NCCI perspective, the definition of differentanatomic sites includes different organs or differentlesions in the same organ. However, it does not includetreatment of contiguous structures of the same organ. Forexample, treatment of the nail, nail bed, and adjacent softtissue constitutes a single anatomic site. Treatment ofposterior segment structures in the eye constitute a singleanatomic site. 
Example: Column 1 Code/Column 2 Code 11055/11720
>CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion (eg,corn or callus); single lesion>CPT Code 11720 – Debridement of nail(s) by anymethod(s); one to fivePolicy: Mutually exclusive proceduresModifier -59 is:1) Only appropriate if procedures are performed for lesions anatomicallyseparate from one another or if procedures are performed at separatepatient encounters.2) Don’t report CPT codes 11055-11057 for removal of hyperkeratotic skinadjacent to nails needing debridement.
Example: Column 1 Code/Column 2 Code 11719/11720>CPT Code 11719 – Trimming of nondystrophic nails, any number>CPT Code 11720 – Debridement of nail(s) by any method(s); one to five
 Policy: Mutually exclusive proceduresModifier -59 is:1) Only appropriate if the trimming and the debridement of the nails areperformed on different nails or if the two procedures are performed atseparate patient encounters
Example: Column 1 Code/Column 2 Code 17000/11100>CPT Code 17000 – Destruction (eg, laser surgery, electrosurgery,cryosurgery, chemosurgery, surgical curettement), all benign orpremalignant lesions (eg, actinic keratoses) other than skin tags orcutaneous vascular proliferative lesions; first lesion>CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucousmembrane (including simple closure), unless otherwise listed; single lesionPolicy: HCPCS/CPT coding manual instruction/guidelineModifier -59 is:1) Only appropriate if procedures are performed on separate lesions or atseparate patient encounters.
Example: Column 1 Code/Column 2 Code 38221/38220>CPT code 38221 - Bone marrow; biopsy, needle or trocar>CPT code 38220 - Bone marrow; aspiration onlyPolicy: Standards of medical/surgical practiceUse of -59 modifier should be uncommon but appropriate for thesecircumstances:1) Different sites - contralateral iliac crests; iliac crest and sternum2) Different incisions - same iliac crest3) Different encounters
Example: Column 1 Code/Column 2 Code 45385/45380>CPT Code 45385 - Colonoscopy, flexible, proximal to splenic flexure; withremoval of tumor(s), polyp(s), or other lesion(s) by snare technique>CPT Code 45380 - Colonoscopy, flexible, proximal to splenic flexure; withbiopsy, single or multiplePolicy: More extensive procedureModifier -59 is:1) Only appropriate if the two procedures are performed on separatelesions or at separate patient encounters.

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