Podiatry Coding & Billing Alert

Use this modifier accurately for proper reimbursement.

Modifier 59 (Distinct procedural service) is used to identify procedures and services that are not normally reported together. It describes a distinct procedural service and should be used when coding for a different session, procedure, or surgery performed on a different site, organ system, lesion, or injury on the same date of service.

When using modifier 59, it’s crucial to make sure that you’re using it correctly and not just trying to sneak past an edit. While modifier 59 is well-known for its ability to indicate a distinct procedural service, it is also one of the most commonly misused modifiers. Therefore, it is crucial to carefully review the documentation and determine if the use of modifier 59 is truly warranted before appending it to a claim.

Below, we will explore some key points regarding the importance of using modifier 59 correctly for successful reimbursement.

View This Real-Life Example

Scenario: A podiatrist performs a primary ankle collateral ligament repair. In the medical documentation, they indicate they made five incisions to repair the single ligament. You should report 27695 (Repair, primary, disrupted ligament, ankle; collateral) on the claim, but how many times can you report that code? This can become confusing because although the podiatrist made numerous incisions, they only repaired the one ligament.

In this case, you should report 27695 only once despite the number of the incisions your podiatrist made to repair the same ligament. Although the podiatrist made multiple incisions, they still only repaired a single ligament, so you would report 27695 only once on your claim.

But if the podiatrist had repaired multiple lateral or medial ligaments on the same date of service, then you could report multiple units of 27695 for each ligament repaired. In this case, you would append modifier 59 when reporting 27695 for two or more repairs. By adding modifier 59 on the claims for the same date of service, you will ensure the payer knows these are not duplicate claims, but claims representing different services. The op notes should specify which ligament(s) the podiatrist repaired in the procedure. Also, make sure the documentation supports the different sites before you append modifier 59.

For example: If your podiatrist repairs multiple ligaments in one of the collateral complexes, such as both the anterior talofibular and calcaneofibular ligaments in the lateral structure, and they make separate incisions for both ligaments, you will report:

• 27695
• 27695-59

Don’t forget: Make sure you pinpoint either the left or right foot by using the correct location modifier, RT (Right side) or LT (Left side), for the repair.

Check Modifier Lists for Multi-Code Claims

Experts agree that whenever you report multiple codes together on a claim in your podiatry practice, you should always check the National Correct Coding Initiative (NCCI)-approved modifier lists, and pay attention to the different modifier indicators. “Before immediately appending modifier 59, always review the modifier lists for a more appropriate/specific modifier,” says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions, Coding Quality & Education Department. “Only use this modifier if it [modifier 59] best describes the circumstances,” noted Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS) during the recent webinar, “The National Correct Coding Initiative and Medically Unlikely Edits.” You should never just use modifier 59 as a default modifier.

Other NCCI-associated modifiers you may see include X modifiers. If anatomical modifiers don’t apply, you should be using the following X{EPSU} modifiers:

• XE (Separate encounter …). Modifier XE is used for a service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
• XP (Separate practitioner …). Modifier XP is used for a service that is distinct because a different practitioner performed it.
• XS (Separate structure …). Modifier XS is used for a service that is distinct because it was performed on a separate organ/structure.
• XU (Unusual non-overlapping service …). Modifier XU is used for a service that is distinct because it does not overlap usual components of the main service. These modifiers are a subset of modifier 59, but they have not replaced modifier 59.

Caution: You should never report modifiers X{EPSU} together with modifier 59 on your claim, Dunphy said. You should only report one modifier or the other. Also, remember that NCCI edits only apply to claims you submit to Medicare or payers that follow Medicare rules.

Know When You Shouldn’t Use Modifier 59

You should never use modifier 59 under the following circumstances:

• You should not append the modifier to an evaluation and management (E/M) service performed on the same date. In that case, you should look to an E/M modifier such as modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).
• If the medical record documentation does not support the separate and distinct status, you cannot use the modifier.
• If the provider performed the same procedure twice on the same day, you should instead look to append modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure by another physician or other qualified health care professional) to the second of the repeated procedures.

The Bottom Line

“In the complex world of medical coding, assumptions can be misleading. It is a common misconception that when an encoder suggests adding a modifier, modifier 59 is automatically applied or recommended by an internal EMR [electronic medical record] edit. However, it is crucial to understand that just because a modifier is allowed, it does not necessarily mean it is supported or appropriate for the specific coding scenario at hand. Precision and context are key when determining the appropriate use of modifiers, as blindly relying on automated suggestions can lead to inaccurate coding and potential reimbursement issues,” says Jennifer McNamara, CPC, CCS, CPMA, CRC, CDEO, COSC, CGSC, COPC, AAPC Approved Instructor, CEO and physician education at Healthcare Inspired, LLC, in Bella Vista, Arkansas.