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Printed Date: 9/22/2015
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:
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:
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.)
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Last Updated: 11/15/2018