Cardiology Coding Alert

Question: I was told that separate ICD-10 codes are not required to report modifier 59. But, we never seem to be able to get paid with this modifier unless we have separate diagnosis codes. Can you advise?

Ohio Subscriber

Answer: Insurers essentially state across-the-board that separate ICD-10 codes are not required to use modifier 59 (Distinct procedural service). For example, CMS’ modifier 59 Fact Sheet says, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure.”

Private insurers typically maintain policies that list similar statements. If your payer specifically tells you that it won’t pay for a modifier 59 claim unless you use separate diagnoses, ask to see that policy in writing. If the payer is unable to produce the policy in writing, then you should appeal the denials as long as your documentation supports the medical necessity and separate nature of the two services.

Bonus: Don’t forget CMS has replaced numerous numeric modifiers with HCPCS modifiers. Please review the following HCPCS modifiers because they may or may not replace modifier 59.

• XE (Separate encounter, a service that is distinct because it occurred during a separate encounter)
• XP (Separate practitioner, a service that is distinct because it was performed by a different practitioner)
• XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure)
• XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).