Many people do not really understand modifiers and when they need to be used. A modifier should never be used just to get higher reimbursement. It shouldn’t be just added on to get a code paid. Modifiers should be used when they are required to describe more accurately the procedure performed or service rendered.
The definition of the 59 modifier per the CPT manual is as follows:
Modifier -59: “Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, 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 physician. 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.”
The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. Unfortunately many times it is used to prevent a service from being bundled or added in with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.
It should also only be used if there is no other more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed then that modifier should be used over the 59 modifier.
When using the 59 modifier to indicate a distinct and separate service, documentation should be in the patient’s medical file to substantiate the use of the 59 modifier. The insurance carrier may request medical records to deem if the 59 modifier is being appropriately used. If a provider is going to bill using the 59 modifier they need to make sure they are documenting the services provided in the patient’s file, showing that the services were distinct and separate.
Use of the 59 modifier does not require that there is a different and separate diagnosis code for each of the services billed. Also, just having different diagnosis codes for each service does not support the use of the 59 modifier.
An example of appropriate use of the 59 modifier might be if a physical therapist performed both 97140 and 97530 in the same visit. Normally these procedures are considered inclusive. If the 59 modifier is appended to either code they will be allowed separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15 minute intervals. If the therapist does the codes simultaneously then the 59 modifier should not be used.
Another example would be if the patient is having a nerve conduction study with cpt codes 95900 and 95903 being billed. If the two procedures are done on separate nerves then the 59 modifier should be used to indicate that. If the codes were performed on the same nerve then the 59 modifier should not be used.
Billers should never add the 59 modifier to a claim even if they know that billing the services without the modifier will result in bundling or a denial. The 59 modifier should only be added by the provider or by a coder who has access to the patient’s chart. If you are the biller and you believe that the 59 modifier would be appropriate but it was not indicated, you should go back to the provider to see if it was omitted by mistake. Don’t just add the modifier to the claim.