CPT modifier 59 - Usage Guidelines.

CPT Modifier 59 -  Distinct Procedural Service

Instructions

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
Correct Use

Different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day 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

    Procedures are performed in different encounters on the same day
    Two services described by timed codes provided during the same encounter only when they are performed sequentially
    Diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
    Diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure

Incorrect Use

    Should not be appended to an E/M service
    Should not be used inappropriately if the basis for its use is that the narrative description of the two codes is different
    When another modifier is more appropriate (e.g. modifier 76 or 91)
    Should not be used to bypass NCCI edits
    Does not replace modifiers such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI

Example

Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable.

This claim example shows CPT 17000 with no modifiers on the first claim line and CPT 11100 with modifier 59 on the second claim line.

Note: If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.
Reminders

Records must evidence a different session or patient encounter, different procedure or surgery, different site or organ system, or separate lesion, incision, excision, injury or area of injury

Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.” 

The 59 modifier should only be used to identify codes that are on the Correct Coding Initiative bundling table, unless specific instructions have been published for additional functions for this modifier. A good example is for multiple anesthesia services on the same day. We published instructions in the Medicare Advisory for use of the 59 modifier on the second anesthesia service. This applies only when a second operative session is involved. We extended this modifier to the Mohs micrographic surgery procedures when a stage is repeated on a different site during the same operative session. The modifier identifies procedures that were performed on a separate site or during a separate operative session.

This modifier does not apply to billing the same procedure code during the same session, such as 20550. If the injection is performed on different knees, then the second 20550 is filed with the 51 modifier. This code falls under the multiple surgery rule, so the second procedure is reduced by 50%. If you billed for multiple digits on the hand, then you would use the digit modifiers, not the 59 modifier. Modifier 59 example: Mrs. Smith comes to your office complaining of multiple lesions. You remove five skin tags from the neck (11200) and perform laser surgery to remove 16 lesions on her back (17004). Procedure code 17004 is on the bundling table bundled into 11200. The procedures are on different sites, so the 59 modifier is applicable. You bill code 11200 on one line and 1700459 on the next line .

Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same day, check modifier 25.


Modifier 59 definition Distinct procedural code


Effective for dates of service January 1, 2015 and following, CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU, and collectively they are referred to as -X{EPSU}.

The -X{EPSU} modifiers are more selective versions of the -59 modifier. (CMS 4,5)

Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

Modifier XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service


Billing and Coding Guidelines


1. Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day 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.

One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated  odifiers – i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI. (See examples 1, 2, and 3) From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be  considered to be separate and distinct. Therefore modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites. For example:

• Treatment of the nail, nail bed, and adjacent soft tissue on the same toe or finger constitutes treatment of a single anatomic site.

• Treatment of posterior segment structures in the eye constitutes treatment of a single anatomic site.

• Arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site.




Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.

There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine the unit of service for both codes), modifier 59 may be used to identify the services.

Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.


When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and
distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic  ntervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT coded  procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Modifiers XE, XS, XP, XU are effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more specific modifier is appropriate.) Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, providers may begin using them for claims with dates of service on or after January 1, 2015. The modifiers are defined as follows:

 XE – “Separate encounter, 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

XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”

XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”

XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”


EXAMPLES OF MODIFIER 59 USAGE

Example 1: Column 1 Code / Column 2 Code - 17000/11100

CPT Code 17000 – Destruction (eg, laser surgery, electrosurgery, cryosurgery,  chemosurgery, surgical curettement), all benign or premalignant lesions (eg, actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion

CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous  membrane (including simple closure), unless otherwise listed; single lesion

Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered
on the same day 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.


Example : Column 1 Code/Column 2 Code 93453/76000

CPT Code 93453 – Combined right and left heart catheterization including intraprocedural injections(s) for left ventriculography, imaging supervision and
interpretation, when performed

CPT Code 76000 – Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy)

CPT code 76000 should not be reported and modifier 59 should not be used for fluoroscopy that is used in conjunction with a cardiac catheterization procedure. Modifier 59 may be reported with code 76000 if the fluoroscopy is performed for a procedure unrelated to the cardiac catheterization procedure.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered
on the same day 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.

Payment Guidelines

CPT codes submitted with modifiers XE, XP, XS, XU, or 59 appended will be considered separately reimbursable when all of the following apply:

** The clinical edit is eligible for a modifier bypass (e.g. per edit rationale, CCI modifier indicator = “1”, etc.).

** CMS policy on the -X{EPSU} modifiers is evolving. If CMS indicates a specific edit may only be bypassed with a specific -X{EPSU} modifier but is not eligible for a bypass with the other -X{EPSU} modifier options or with modifier 59, Moda Health will follow those specific requirement as well.

“For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.”

** The CPT code is not considered a bundled component of a more comprehensive procedure (code definitions, standards of medical & surgical practice, etc.).

** The modifier and the code have been submitted in accordance with AMA CPT book guidelines, CPT Assistant guidelines, CMS/NCCI Policy Manual guidelines, and any  applicable specialty society guidelines.

** The medical records documentation supports the appropriate use of modifiers XE, XP, XS,  XU, or 59.

** The procedure code is eligible for separate reimbursement according to the status indicators on the CMS fee schedule for the relevant provider type (physician fee schedule, ASC, OPPS, etc.).


The submission of modifiers XE, XP, XS, XU, or 59 appended to a procedure code indicates that documentation is available in the patient’s records which will support the distinct or independent identifiable nature of the service submitted with modifier XE, XP, XS, XU, or 59, and that these records will be provided in a timely manner for review upon request.

Modifiers XE, XP, XS, XU, and/or 59 do not bypass multiple surgery fee reductions, bilateral fee adjustments, or any other administrative policy other than clinical edits.


Reporting and Documentation Rules and Criteria for Modifier 59:


The reporting of modifier 59 by a provider must follow the Health Plan’s requirements for correct coding.

• The Health Plan requires that modifier 59 must be appended to the denied code as described in the National Correct Coding Initiative (NCCI) Column 1/Column 2 edits

• We follow CPT′ coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and “only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Documentation is not required for a claim to be processed when modifier 59 is appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. The Health Plan follows CPT in requiring that documentation must support:

• a different session or patient encounter
• a different procedure or surgery
• a different anatomical site or organ system
• a separate incision/excision
• a separate lesion
• a separate injury

The following example indicates the appropriate use of modifier 59 when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported.

• A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71010 will be denied separate reimbursement.

• When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 to CPT 71010 is warranted to signify that a separate and distinct service was performed. (Modifier 59 should follow modifier 26, if services are done in a facility setting.) Modifier 59 will override the procedure unbundling edit and 71010 will be eligible for separate reimbursement.

If you have more than one surgery code for the same day of service, which code do you use? Do we continue to use 59? 

A: The rules for Modifier 59 usage have not changed. The provider should check NCCI edits prior to claims submission to verify if appending any modifier to their claim is appropriate/allowed. Modifier 59 would not appropriately be filed if it is used to indicate that a single procedure code was performed more than once per day (repeat service). Modifier 76 or an anatomical modifier is the appropriate modifier to indicate that the same procedure code was repeated more than once per day.


Anatomical modifiers with the same procedure codes times two (2), do you now want the use of the 76 modifier and the correct multiple anatomical modifiers, or the 59 modifier to identify separate anatomical site.

A: Modifier 59 should not be used to indicate that a procedure code was performed more than once per day. If the same procedure code is performed more than once and there are anatomical modifiers to indicate that the services were performed in different sites, then those should be used. If there is no anatomical modifier to indicate that the procedure was performed more than once on the same day, then modifier 76 would be necessary to show that the procedure is a repeat


If a patient is taken to surgery twice on the same date of service, we have been using the modifier 59 on the second Anesthesia case. Is this still correct? 

A: Modifier 59 is not appropriate to indicate that the same procedure was performed more than once per day. If the same anesthesia procedure is performed more than once per day, then modifier 76 would need to be appended to the procedure in addition to the appropriate anesthesia modifiers.


Coding Guidelines

“Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.”


“Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.”


Other specific appropriate uses of modifier 59 

There are three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter.

a. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.

There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine the unit of service for both codes), modifier 59 may be used to identify the services. (See example 9)

b. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic  procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 10) If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

c. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 11) If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately. Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.




Different Diagnosis

“Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.”

Different Organs/Contiguous Structures

“From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.” (CMS 2 )

“If multiple bacterial blood cultures are performed, including isolation and presumptive identification of isolates, code 87040, Culture, bacterial; blood, aerobic, isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate), should be used to identify each culture procedure performed. Modifier 59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.”

Modifier 25 and 59 usage

Modifiers are two-digit codes appended to procedure codes and/or HCPCS codes to provide additional information about the billed procedure. In some cases, addition of a modifier may directly affect payment. Below is a list of the most frequently used modifiers including the modifier description and instructions for proper use.

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

• Modifier 25 indicates the patient’s condition on the day of the procedure required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service performed.

• Bill modifier 25 with the appropriate level of E/M service.

• Bill modifiers 24 and 25 when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.

59: Distinct procedural service

• Modifier 59 indicates a procedure or service was distinct or separate from other services performed on the same day.

• Represented by a different session or patient encounter, different procedure or surgery, different site, separate session, or separate injury (or area of injury)

• Modifier 59 indicates the secondary, additional, or lesser procedure.

• Modifier 59 is not valid on E/M codes.

• Use modifier 59 if no other valid modifier exists. CMS established modifiers indicating services provided on the same date to different anatomic sites (i.e., for eyelids, E1 through E4; for fingers FA, and F1 through F9; for toes, TA, and T1 through T9; LT and RT).


Modifier 59 for therapy services

One of the common uses of modifier 59 is for theraputic procedure that performed at different anatomic sites are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers. From an NCCI perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. However, NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. Therefore modifier 59 should only be used to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites.

When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example 10) If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.


An effort to decrease abuse of filling for procedure codes, the National Correct Coding Initiative NCCI) edits were developed by the Centers for Medicare and Medicaid Services (CMS).

The NCCI edit program is used by carriers and third party administrators in an effort to thwart abusive billing practices of codes that should not be used together.

For doctors of chiropractic, three common therapeutic procedure codes are identified by the edits when billed with chiropractic manipulative treatment (CMT) codes: 98940, 98941, and 98942. These procedure codes are 97112 neuromuscular re-education, 97124 massage therapy, and 97140 manual therapy.

Exceptional circumstances

There are exceptions to the NCCI edits. One is when the 59 modifier is used to indicate to the carrier that a “distinct procedural service” is involved and the procedures should be paid separately. Unfortunately, the 59 modifier is also an oft-abused and erroneously used modifier. This prompted CMS to release new subsets of the 59 modifier in January 2015.

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non- evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

 Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.

When another already-established modifier is appropriate, however, it should be used rather than modifier 59. If no further descriptive modifier is available, and the use of modifier 59 best explains the circumstances, only then should modifier 59 be used.

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