Orthopedic Coding Alert

Clinical examples help clear up common misconceptions I personally think that modifier 59 is one of the best modifiers that exists. It is also one of the most misunderstood modifiers. The objective of this article is to bring to light the correct use of modifier 59. Modifier 59 (Distinct procedural service) was established to demonstrate that a single provider performed multiple -- yet distinct -- services to a patient on the same date of service. Because distinct procedures or services rendered on the same day by the same physician cannot be easily identified and therefore properly adjudicated by simply listing the CPT procedure codes, modifier 59 assists the third-party payer or Medicare carrier in applying the appropriate reimbursement. If the modifier is not used in these circumstances, a denial of services may result with an explanation of benefits stating, for instance for Medicare claims, "Medicare does not pay for this service because it is part of another service that was performed at the same time." Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not usually encountered or performed on the same day by the same physician. At the same time, this is the modifier of last resort. If no other modifier is available or appropriate and using modifier 59 best explains the circumstances, then you should use it. Using the Modifier Correctly Use modifier 59 when billing a combination of codes that you normally would not bill together. This modifier indicates that the ordinarily bundled code represents a service done at a different anatomical site or at a different session on the same date. This may represent: - different procedure or service on the same day - different anatomical site or organ system (such as a skin graft and an allograft in different locations) - separate incision/excision - separate lesion (such as a biopsy of skin on the neck performed during the same session as an incision of a 1.0-cm benign lesion of the back) - separate injury. Use modifier 59 only on the procedure designated as the distinct procedural service. The physician needs to document that a procedure or service was distinct or separate from other services performed on the same day. Ensure that the medical record documentation is clear as to the separate and distinct procedure before appending modifier 59 to a code. This modifier allows the code to bypass edits, so appropriate documentation must be present in the record. Note: Medicare uses the Correct [...]