The use of modifier -59 (distinct procedural service) can be a double-edged sword for general surgery practices.
Typically, -59 is used to identify procedures performed on the same day that normally would not be reported together because they are bundled in a global package. Under certain circumstances, however, general surgeons may use modifier -59 to indicate that a procedure was distinct or independent from other services performed during the same 24-hour period.
According to CPT 1999, This may represent a 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 effect of adding the -59 modifier to the secondary procedure is to unbundle the two procedures in the global period, overriding the automatic edits of private payers and Medicares Correct Coding Initiative edits.
Use Modifier -59 Cautiously
Because of its unbundling capability use of the -59 also can be a red flag for medical review; if used incorrectly, it could lead to an audit or worse. Furthermore, improper use of this modifier indirectly penalizes those practices that utilize it correctly, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ, which does general surgery reimbursement.
Unfortunately, many general surgeons use the -59 to obtain reimbursement for procedures that should not be unbundled. For example, some
general surgery coders bill 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s][separate procedure]) with the -59 modifier attached when the laparotomy was performed to allow access for the primary procedure.
In effect, using the -59 in this scenario tells payers that the surgeon performed the exploratory laparotomy and then later the same day, an appendectomy or colectomy was performed, when in fact both procedures occurred during the same session.
In the short term, the misuse of -59 may result in payment; however, should you be audited later, there would likely be adverse consequences for the practice.
Use For Different Times or Different Sites
Some procedures performed at different times on the same day may be billed with modifier -59. For example, a surgeon may perform a 36533 (insertion of implantable venous access port, with or without subcutaneous reservoir) in order to administer medication to a patient over the long term. But later the same day, the patients condition deteriorates and the surgeon has to insert a central line that requires a cutdown because the patients veins are [...]
