Use Caution With Modifier -59

Allergy coders may be tempted to use modifier -59 to unbundle procedures such as 95115 and 95117 or to receive reimbursement for multiple nebulizer treatments provided to the same patient on the same day. But modifier -59 (Distinct procedural service) can raise red flags with carriers, inviting audits and even fraud allegations, experts warn, so use it carefully.
According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." In essence, modifier -59 tells the insurer, "Although these services/procedures appear related, they are, in this case, separate," says Laureen Jandreop, OTR, CPC, CCS-P, CPC-H, CCS, owner and CPC trainer for A+ Medical Management and Education in Absecon, N.J.
Unbundle 95004 and 95078 With -59
Coders have frequently used modifier -59 to unbundle component codes from their comprehensive code (according to CCI edits), which has carriers keeping a close eye on all claims that employ modifier -59. This carrier vigilance makes it all the more important that coders are selective about circumstances that require -59.
For instance, CCI usually considers a skin test (95004, Percutaneous tests [scratch, puncture, prick] with allergenic extracts, immediate type reaction, specify number of tests) and provocative testing (95078, Provocative testing [e.g., Rinkel test]) as mutually exclusive procedures. However, if these procedures are provided on the same date of service, but at different body locations, coders can appropriately append modifier -59 to 95078 to indicate that the two procedures are independent and separately billable.
But don't immediately assume that modifier -59 is the most appropriate modifier to use. Modifier -59 is not a "catchall," CPT instructs, and should be reported only if no other more specific modifier applies. Consider using one of the global surgery modifiers -58, -78 and -79 before assuming -59 is the only suitable modifier, says Linda S. Dietz, RHIA, CCS, CCS-P, coding specialist for the National Correct Coding Initiative.
Before you append -59, be sure you have met at least one of the criteria for this modifier. According to CCI guidelines, modifier -59 applies only to circumstances in which a procedure that would normally be bundled with another procedure should not be bundled because:


It was performed in a separate surgical session or patient encounter from the procedure(s) with which it would normally be bundled.


It is a different, distinct and separate procedure or surgery from the one with which it would normally be bundled. (Note: This must be medically necessary as indicated by different diagnosis codes.)

It is done in a different site or organ system. [...]

- Published on 2002-09-01