Gastroenterology Coding Alert

Learn when other modifiers might be more appropriate.

Through the years, modifier 59 (Distinct procedural service) often tops the list of most inappropriately used — and most confusing — codes. It’s generally considered to be a modifier that requires significant education.

If your claims are frequently denied because of 59, keep reading for clarification on when — and when not — to append this misunderstood modifier.

Review the Modifier 59 Basics

Modifier 59 was created about 30 years ago. Basically, it’s used “to indicate that a product or a procedure or service is distinct or separate. Now doesn’t that seem like it should be very easy? Is it? No,” said Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, CGSC, CHONC, Director of Client Engagement at AAPC Services, out of New London, MO during the HEALTHCON 2023 presentation “Modifier 59: The Other Misused Modifier” in Nashville, TN.

The CPT^® manual defines modifier 59 as follows:

“Distinct Procedural Service: … Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, 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 individual.”

While there are other reasons to use this modifier, “[National Correct Coding Initiative] NCCI edits are the main reason,” explained Cox. “It provides a way for us to be able to report multiple services that are done at the same session on the same date that might be considered bundled by the powers that be,” she continued.

Example: For an upper GI endoscopy with dilation, which you might report with 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter), report 43239-59 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) if your gastroenterologist also biopsied a lesion in a different site during that same procedure (edits preclude payment for biopsy of same site dilated)

Beware 59’s Bad Reputation

Even though the modifier can be useful, overuse and misuse is prevalent “across all payers, across all specialties,” said Cox. In fact, in a recent False Claims Act (FCA) case, a vascular surgeon in Michigan faced massive fines and jail time. One of his alleged crimes- was the improper use of modifier 59 to unbundle services that should have been billed together in a single claim to boost his reimbursements from federal health care programs, the Department of Justice says in a release. (You can review case specifics here: www.justice.gov/opa/pr/michigan-vascular-surgeon-sentenced-80- months-prison-health-care-fraud-conviction-and-agrees.)

This is an extreme case, but it’s a good example of how serious misuse of this modifier can lead to compliance issues. This particular case is an example of fraud because this surgeon allegedly misused the modifier intentionally, but most of the time, “it’s abused because they [coders and providers] just don’t understand how to use it and how to get it done right,” said Cox.

Don’t Default to 59

Performing two procedures does not automatically mean you’ll need to append the 59 modifier. Commonly, coders will append modifier 59 for all separate procedures, regardless of whether they’re even bundled, which will result in denial every time.

Example: The provider preps the patient for an esophagogastroduodenoscopy (EGD) and inserts the scope. The scope cannot pass the esophagus due to a mass that has blocked nearly the entire distal esophageal area. The provider takes a biopsy and sends it for immediate results. The pathologist calls soon to say there’s malignancy. Before undergoing anesthesia, the patient had consented to an open procedure if necessary, so the provider made the decision to convert to open based on the size of the mass and likelihood of cancer. The procedure goes smoothly.

For this, you’d report 43202 (Esophagoscopy, flexible, transoral; with biopsy, single or multiple) and 43117 (Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)). According to the NCCI edits, these two codes are not bundled, which means they can be billed separately without the modifier.

Differentiate 59 from X{EPSU}

Temptation to default to the 59 modifier tends to extend to circumstances when another modifier is better suited for the situation. You always want to use the modifier that is most appropriate.

In an attempt to mitigate the common 59 modifier issues, The Centers for Medicare & Medicaid Services created the X{EPSU} modifiers, which allow you to more specifically report a distinct procedure. So, consider looking at the following when billing Medicare or payers following Medicare rules:

• XE (Separate encounter …). You’ll use modifier XE for a service that is distinct because it occurred during a separate encounter. Only use this modifier to describe separate encounters on the same date of service.
• XP (Separate practitioner …). Turn to modifier XP for a service that is distinct because a different practitioner performed it.
• XS (Separate structure …). Modifier XS should be your choice for a service that is distinct because it was performed on a separate organ/structure.
• XU (Unusual non-overlapping service …). Finally, use modifier XU for a service that is distinct because it does not overlap usual components of the main service.

Expert tip: “If modifier 59 were an ICD-10-CM code, it would be considered unspecified, Vanderbilt explained. The X{EPSU} modifiers are the equivalent of reporting 59 with a higher level of specificity,” Vanderbilt said. If the X{EPSU} modifiers don’t apply, it is likely that your services should not be unbundled, Vanderbilt said. That means that instead of two CPT^® codes, you should only report one.

Caution: Some payers prefer 59 to the X modifiers, and some prefer the X modifiers over the 59. Be sure to check with the payer to avoid denials, warns Cox.