Orthopedic Coding Alert

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.

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 Coding Initiative (CCI) screens when editing claims for possible unbundling. Under CCI screens, specific codes have been identified that you should not bill together.

You can find these online at http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.

Beware these four mistakes:

- appending modifier 59 to E/M codes

- using the modifier as a replacement for modifiers:

- 24 -- Unrelated evaluation and management service by the same physician during a postoperative period

- 25 -- Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

- 51 -- Multiple procedures

- 78 -- Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period

- 79 -- Unrelated procedure or service by the same physician during the postoperative period

- using modifier 59 when another modifier better describes the distinct service

- reporting modifier 59 with modifier 51 on the same CPT code.

Example 1: A patient presents for a diagnostic endoscopy that results in a decision to perform an open surgical procedure. You should report the diagnostic endoscopy using modifier 59 to indicate a distinct diagnostic service when performed at a separate session.

Example 2: A scar revision is performed on a painful colloid of a patient's foot, originally caused by stepping on glass five years previously. The original wound was never sutured. The procedure is complex because the scar measures 3.3 cm and the repair is tedious. During the same session, the physician noted a lesion on the patient's right calf and obtained a skin biopsy.

In this case, you should submit codes 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm) and 11100-59 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

Bottom line: Modifiers can be very confusing. If you use them correctly, your reimbursement may be increased and, sometimes, unfortunately decreased. Overall, modifiers are all about money, so use them wisely and correctly. Avoid those denials and underpayments with the correct usage.

-- Darlene Boschert, CPC, CPC-H, CCP, CMM, CHCO, CMT, CMA, is director and lead instructor for the Allied Health Programs for the Career Institute of Florida in St. Petersburg. She is a national consultant, speaker and audioconference presenter and past member of the AAPC National Advisory Board.