The keys to understanding modifier -59 perhaps the trickiest modifier in the book can be found in the book itself. "Look at modifier -59 as a tool," Cobuzzi says. When you receive denials that you disagree with, consider using modifier -59 if you can apply its definition to the particular situation at hand.
The definition of modifier -59 (Distinct procedural service) found in the CPT manual lists three components that provide a checklist for coders to follow.
"Modifier -59 is not a universal unbundler," says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "You should not consider the modifier a way to unbundle procedures or services."
"Use a -59 to explain that a procedure which is usually bundled is separate and distinct in this particular situation," agrees Staci Jordan CPC, CCS-P, reimbursement analyst for the University of Oklahoma Health Sciences Center in Oklahoma City. "Check the Correct Coding Initiative for procedures which CMS designates as incidental and require modifier -59 for separate payment," she says.
CCI states, "A 1 indicates that a modifier is allowed in order to differentiate between the services provided."
"Modifiers tell a story about why something should be paid more or paid less." They help carriers understand why two procedures that an insurer would not normally reimburse separately should be paid that way.