Podiatry Coding & Billing Alert

Remember: Never append modifier 59 to E/M services.

As a coder, you’ve probably encountered modifier 59 (Distinct procedural service), also known as the “unbundling modifier.” But, National Correct Coding Institute (CCI) has many rules for when and if you can appropriately unbundle procedure-to-procedure (PTP) edit pairs.

Read on to make sure modifier 59 never trips you up again.

Follow CMS’s Guidelines for Modifier 59

You may use modifier 59 when you can document circumstances that result in the provider performing multiple procedures that don’t usually occur together.

CMS puts it this way in the Medicare Claims Processing Manual Chapter 23, (updated in Transmittal 4188 dated December 28, 2018):

• Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
• Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.
• Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

Coding example:  The podiatrist performs an ankle ligament repair where he repaired both the talofibular and calcaneofibular ligaments in the lateral structure. He made separate incisions for both ligaments. You should report the following CPT^® codes:

• 27695 (Repair, primary, disrupted ligament, ankle; collateral)
• 27695-59.

On the other hand, if the podiatrist repairs just a single ligament, you would report 27695 only once. If the podiatrist makes multiple incisions to repair a single ligament, you would still report 27695 only once.

Separate ICD-10 Codes Not Required to Append Modifier 59

Insurers essentially state across-the-board that separate ICD-10 codes are not required to use modifier 59 (Distinct procedural service). For example, CMS’ modifier 59 Fact Sheet says, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure.”

Important: Private insurers typically maintain policies that list similar statements. If your payer specifically tells you that it won’t pay for a modifier 59 claim unless you use separate diagnoses, ask to see that policy in writing. If the payer is unable to produce the policy in writing, then you should appeal the denials as long as your documentation supports the medical necessity and separate nature of the two services.

Don’t Just Rely on Modifier 59

Modifier 59 is not the only modifier you can use to unbundle procedures. If the situation allows, you may be able to use modifiers for specific anatomic sites, including RT (Right side), LT (Left side) and modifiers for specific fingers (F1-F9 and FA) and toes (T1-T9 and TA).

Additionally, since 2015, you have also had the option to use one of the X{ESPU} modifiers CMS introduced to eventually replace 59:

• XE (Separate encounter …)
• XS (Separate structure) …)
• XP (Separate practitioner …)
• XU (Unusual non-overlapping service…).

More and more payers are recognizing these modifiers, so be sure to check with them before using one when the situation allows.

Although CMS officially accepts these modifiers, you should ensure that your Medicare Administrative Contractor (MAC) processes claims using them before you report them.

“The X-modifiers better define why you feel the need to modify the service you are submitting,” explains Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “But it is important to understand the payer. What do they want to see? Do you need to send notes? And does the documentation clearly support the separate nature of the two services?”

Never Append Modifier 59 to E/M Services

“You would never use modifier 59 on an E/M service,” explains Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

If you’re overriding an edit pair that includes an E/M code, you should instead turn to 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)  or 57 (Decision for surgery).