General Surgery Coding Alert

Modifier -59 (Distinct procedural service) is a powerful tool to increase payments, but improper use can lead to denied claims, audits or fraud allegations.

This modifier allows surgeons to receive separate reimbursement for procedures that the Correct Coding Initiative (CCI) usually bundles if provided on the same date of service but in a particular instance were distinct or independent of one another. When Is -59 Appropriate? According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." In essence, modifier -59 tells the insurer, "Although these services/procedures appear related, they are, in this case, separate," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education in Egg Harbor City, N.J. Such circumstances may include the following:

a different session or patient encounter
a different procedure or surgery
a different site or organ system
a separate incision/excision, lesion or injury or area of extensive injury not ordinarily encountered or performed on the same day by the same physician. For instance, a surgeon implants a subcutaneous reservoir to administer long-term medication (36533, Insertion of implantable venous access device, with or without subcutaneous reservoir). A few hours later, the patient's condition worsens, and complications contraindicate using the subcutaneous reservoir. Therefore, the surgeon opts to place a central line (36491*, Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperali-mentation, hemodialysis, or chemotherapy]; cutdown, over age 2) to provide immediate relief. Although CCI lists 36533 and 36491 as mutually exclusive procedures, in this circumstance medical necessity dictates using a central line following reservoir placement. You may report both codes, but to indicate the separate, unusual nature of the cutdown catheter (and to override the CCI code pair edit), you must append modifier -59 to 36491. Provide supporting documentation to justify the claim. Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code, Jandroep says. Only CCI edits with a status indicator of "1" may be unbundled using modifier -59. You may not unbundle those code combinations with a status indicator of "0" under any circumstances. You need not append modifier -59 if CCI does not bundle the multiple procedure codes you are billing. For more information on CCI edits, see General Surgery Coding Alert, November 2002. Learn From More Coding Examples Surgeons will find many instances in which modifier -59 is appropriate. For example, a surgeon tends to a child with multiple leg wounds who has fallen from a playground swing. She performs intermediate repair and closure for several wounds on the child's right leg, [...]