General Surgery Coding Alert

Question: What is the difference between modifiers -59 and -51? During preparation for the CPC exam, I read that when a physician performs an esophagogastroduodenoscopy (EGD) and a colonoscopy on the same day, modifier -51 is used to indicate multiple procedures. Would modifier -59, which fits the description of two separate anatomical sites for two separate problems/diagnoses, be appropriate in this case? We have been advised, however, that modifier -59 can trigger an audit. Can you clarify?

Oregon Subscriber

Answer: The descriptor for modifier -59 (distinct procedural service) states that it should be used for procedures/services that are not normally reported together. This indicates that these codes normally are bundled together, or that one of the procedures has been designated a separate procedure by CPT and therefore is not billable if any other procedures have been performed in the same area, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a coding and reimbursement consulting firm in Lakewood, N.J.

Therefore, modifier -59 should be used only for what it was specifically created to do override national Correct Coding Initiative edits (or other bundles, such as those arising from a services CPT status as a separate procedure) when appropriate.

Because EGDs and colonoscopies normally are not bundled, there is no need for modifier -59, Cobuzzi says, noting that modifier -59 is appropriately used to indicate that two procedures normally not billed together were performed at different times or at different locations in the body.

For example, if the surgeon performs a diagnostic colonoscopy in the morning, the patient hemorrhages in the afternoon and the physician has to bring him or her back to the operating room to perform a colonoscopy with control of hemorrhage, modifier -59 would be used on the diagnostic colonoscopy (the lower RVU procedure) to indicate that the two procedures were undertaken during separate sessions.