Modifier 59 Fact Sheet
Modifier 59 Fact Sheet
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Definition: Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.
Appropriate Usage
- Documentation indicates two separate procedures 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 Modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits.
- Use Modifier 59 when there is no other appropriate modifier.
- Use 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.
Correct Use of Modifier 59 with Cytopathology Codes
When cytopathology codes are reported, the appropriate CPT code to bill is that which describes, to the highest level of specificity, what services were rendered. Accordingly, for a given specimen, only one code from a group of related codes describing a group of services that could be performed on a specimen with the same end result (e.g., 88104-88112, 88142-88143, 88150-88154, 88164-88167, etc.) is to be reported. If multiple services (i.e., separate specimens from different anatomic sites) are reported, modifier -59 should be used to indicate that different levels of service were provided for different specimens from different anatomic sites. This should be reflected in the cytopathologic reports.
Inappropriate Usage
- Code combination not appearing in the NCCI edits
- Submission of Evaluation and Management (E/M) Codes
- Submission of weekly radiation therapy management codes (CPT 77427)
- The NCCI tables lists the procedure code pair with a modifier indicator of "0"
- Documentation does not support the separate and distinct status
- Exact same procedure code performed twice on the same day
- Multiple administration of injections of the same drug
- If a valid modifier exists to identify the services
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