Appropriate Usage of the Modifier for a Distinct Procedural Service, Other Than E/M Services

CPT modifier 59 is the distinct procedural service modifier reported with a Current Procedural Terminology (CPT^®) code to identify procedures/services, other than Evaluation and Management (E/M) services that are not normally reported together, but appropriately billable under certain circumstances.

Appropriate usage includes:

• Use CPT modifier 59 when documentation indicates two separate procedures were performed on the same day by the same physician
  • Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)
• Use CPT modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits
• Use CPT modifier 59 when there is no other appropriate modifier
• Use CPT modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service
• CPT modifier 59 is a modifier that can be broadly applied. As a widely used modifier, it is both commonly used and commonly abused. Given these circumstances, the NCCI has Procedure to Procedure (PTP) edits to prevent unbundling and incorrect payment to providers and outpatient facilities.

The Office of the Inspector General (OIG) performed an analysis in fiscal year (FY) 2003 regarding the proper usage of CPT modifier 59 to determine whether the modifier was being used inappropriately to bypass Medicare’s National Correct Coding Initiative (NCCI) edits. Forty percent of code pairs billed with CPT modifier 59 did not meet program requirements, resulting in $59 million in improper payments. Specifically, CPT modifier 59 was used inappropriately with 15 percent of the code pairs because the services were not distinct from each other. Eleven percent of code pairs billed with CPT modifier 59 were paid when the modifier was billed with the incorrect code.

Even with the NCCI PTP edits in place, according to the 2013 CERT Report Data, approximately $2.4 billion in Medicare payments were associated with CPT modifier 59 payments with $320 million in projected error rates. The total projected error rate for this modifier alone is $770 million for just one year. Although the projected error rate is not entirely due to potential misuse of CPT modifier 59, its overuse/abuse equals at least $77 million per year in improper claims payment. The report noted that incorrect modifier usage was a major contributing factor.

In 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. In this situation when another already established modifier is appropriate, it should be used rather than CPT modifier 59. Only if there is not a more descriptive modifier available, and the use of CPT modifier 59 best explains the circumstances, should CPT modifier 59 be used. It is incorrect to append CPT modifier 59 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, consider using CPT modifier 25.

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.  Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. NCCI edits are also typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct.

CPT 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. CPT modifier 59 is sometimes used inappropriately if the basis for its use is that the narrative description of the two codes is different

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:

• CPT modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. If two timed services are provided in time periods that are separate and distinct and not interspersed with each other (i.e., one service is completed before the subsequent service begins), CPT modifier 59 may be used to identify the services.
• 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 it meets the following criteria:
  • Occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention
  • Clearly provides the information needed to decide whether to proceed with the therapeutic procedure
  • Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.
• CPT 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. 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.

HCPCS modifiers XE, XS, XP, and XU became effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where CPT modifier 59 was previously reported and may be utilized in lieu of CPT modifier 59 whenever possible. Remember, CPT modifier 59 should only be utilized if no other more specific modifier is appropriate. Although use of the 'X' HCPCS modifiers is not yet required, providers may use them for claims with dates of service on or after January 1, 2015. (See SE 1418 for definitions of 'X' HCPCS modifiers.)

Resources:

• Change Request (CR) 8863 (PDF, 60 KB)
• Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits (PDF, 671 KB)
• Special Edition MLN Matters (SE1418): Proper Use of Modifier 59 (PDF, 340 KB)
• National Correct Coding Initiative Policy Manual