Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. CPT 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 or patient encounter, 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 physician
  • The most common use of CPT modifier 59 is to allow separate reimbursement for services that would normally be "bundled" by the Correct Coding Initiative (CCI) edits
  • For CCI, the primary purpose of CPT modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationship of the procedure codes. It is appropriate to submit this modifier if the two procedures are performed at different anatomic sites or during different patient encounters.
  • Note: For CCI purposes, the definition of "different anatomic sites" includes different organs or different lesions in the same organ. It does not, however, include treatment of contiguous structures of the same organ (e.g., treatment of the nail, nail bed, adjacent soft tissue or of the posterior segment structures in the eye).
  • In all cases, documentation in the patient’s medical record must support the use of CPT modifier 59
  • Before submitting this modifier, it is important to verify whether the services are bundled through CCI. CCI edits may be updated as often as quarterly. Access the CMS website for the National Correct Coding Initiative.
  • Code pairs identified with indicator 0 in the CCI list cannot be submitted separately for reimbursement under any circumstances. There are no exceptions to the CCI edits for indicator 0 codes.
  • Code pairs identified with indicator 1 may be submitted separately for reimbursement if the two services are performed in a different session or patient encounter, 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 physician. Documentation must be maintained in the medical record to support the use of this modifier. No special documentation is required with the claim when CPT modifier 59 is submitted.
  • Code pairs identified with indicator 9 are not subject to CCI edits. No modifier is required in these situations.
  • When another modifier is appropriate, it should be used rather than CPT modifier 59
  • Under most circumstances, CPT modifier 59 is not appropriate for use with E/M or surgical procedure codes. One exception is multiple facet joint injections. These procedures are not staged, so CPT modifier 58 is not appropriate. These are not considered "repeat procedures," so CPT modifier 76 is not appropriate. In these circumstances, it is appropriate to submit CPT modifier 59 when the facet joint injections are performed at multiple levels.

CPT Modifier 59 Coding Examples
Podiatry: Example 1

  • CPT code 11055 (CCI — column I code): Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion, submitted with:
    • CPT code 11720 (CCI — column II code): Debridement of nail(s) by any method(s); one to five

Rationale:

  • These are mutually exclusive procedures for CCI purposes
  • CPT modifier 59 is only appropriate in this situation if these procedures are performed for lesions that are anatomically separate from one another or if procedures are performed at separate patient encounters
  • Do not submit CPT codes 11055 through 11057 for removal of hyperkeratotic skin adjacent to nails needing debridement

Podiatry: Example 2

  • CPT code 11719 (CCI — column I code): Trimming of nondystrophic nails, any number, submitted with:
    • CPT code 11720 (CCI — column II code): Debridement of nail(s) by any method(s); one to five

Rationale:

  • These are mutually exclusive procedures for CCI purposes
  • CPT modifier 59 is only appropriate if the trimming and the debridement of the nails are performed on different nails or if the two procedures are performed at separate patient encounters
These are mutually exclusive procedures for CCI purposes.

Dermatology: Example 3

  • CPT code 17000 (CCI — column I code): Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion, submitted with:
    • CPT code 11100 (CCI — column II code): Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Rationale:

  • Correct usage of CPT modifier 59 is based on CPT coding manual instructions and guidelines
  • CPT modifier 59 is only appropriate if the procedures are performed on separate lesions or at separate patient encounters

Hematology/Oncology: Example 4

  • CPT code 38221 (CCI — column I code): Bone marrow; biopsy, needle or trocar, submitted with:
    • CPT code 38220 (CCI — column II code): Bone marrow; aspiration only   

Rationale:

  • Correct CPT modifier 59 usage in this situation is based on standards of medical/surgical practice

CPT modifier 59 should be uncommon but is appropriate if the procedures are performed at either:

  • Different sites — contralateral iliac crests; iliac crest and sternum
  • Different incisions — same iliac crest
  • Different encounters

Gastroenterology: Example 5

  • CPT code 45385 (CCI — column I code): Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, submitted with:
    • CPT code 45380 (CCI — column II code): Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple

Rationale:

  • Correct usage of CPT modifier 59 in this situation is based on a 'more extensive procedure'
  • CPT modifier 59 is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters

Surgery: Example 6

  • CPT code 47370 (CCI — column I code): Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency, submitted with:
    • CPT code 76942 (CCI — column II code): Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Rationale:

  • Correct usage of CPT modifier 59 is based on CPT coding manual instructions and guidelines
  • CPT modifier 59 is only appropriate if the ultrasonic guidance (CPT code 76942) is performed for a procedure that is unrelated to the surgical laparoscopic ablation procedure

Cardiology: Example 7

  • CPT code 93015 (CCI — column I code): Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report, submitted with:
    • CPT code 93040 (CCI — column II code): Rhythm ECG, one to three leads; with interpretation and report

Rationale:

  • Correct usage of CPT modifier 59 is based on whether the additional procedure is more extensive
  • CPT modifier 59 is only appropriate if the rhythm ECG service (CPT code 93040) is performed unrelated to the cardiovascular stress test at a different patient encounter

Cardiology: Example 8

  • CPT code 93529 (CCI — column I code): Combined right heart catheterization and left heart catheterization through existing septal opening (with or without retrograde left heart catheterization), submitted with:
    • CPT code 76000 (CCI — column II code): Fluoroscopy (separate procedure), up to one hour physician time, other than CPT code 71023 or 71034 (e.g., cardiac fluoroscopy)

Rationale:

  • Correct usage of CPT modifier 59 is based on standards of medical/surgical practice
  • CPT modifier 59 is only appropriate if the fluoroscopy service (CPT code 76000) is performed for a procedure that is unrelated to the cardiac catheterization

Electrophysiology: Example 9

  • CPT code 95903 (CCI — column I code): Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study, submitted with:
    • CPT code 95900 (CCI — column II code): Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

Rationale:

  • Correct usage of CPT modifier 59 is based on whether the additional procedure is more extensive
  • CPT modifier 59 is only appropriate if the two procedures are actually performed on different nerves or in separate patient encounters

Physical Medicine: Example 10

  • CPT code 97140 (CCI — column I code): Manual therapy techniques (e.g. mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes, submitted with:
    • CPT code 97530 (CCI — column II code): Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Rationale:

  • These are mutually exclusive procedures for CCI purposes
  • CPT modifier 59 is only appropriate if the two procedures are performed in distinctly different 15-minute intervals. The two codes cannot be reported together if they are performed during the same 15-minute interval.

Laboratory Services: Example 11

  • CPT code 83721 (CCI — column II code): LDL cholesterol, submitted with:
    • CPT code 80061 (CCI — column I code): lipid panel
  • Note: In most cases, CPT code 83721 is not separately reimbursable from CPT code 80061. Do not submit CPT code 83721 with CPT modifier 59 when CPT code 80061 is performed on the same date. 

Rationale:

  • These services are generally performed during the same patient encounter and are rarely separately reimbursable

Reference:

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

Email JJ Part B

Contact a specific JJ Part B department



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