So how is modifier 59 supposed to be used?

By Raymond Janevicius, MD
07/12/2011 at 2:00PM

The correct use of modifier 59 continues to confuse surgeons, coders and payers. Requirements by payers have transcended the original intent of the modifier, and surgeons have found guidelines for its use applied inconsistently. This month's column will attempt to demystify modifier 59.

What does CPT say?

Modifier 59 is the "Distinct Procedural Service" modifier. CPT states: 

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 raqther 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.

The intent of modifier 59 is to distinguish procedures and services which are "not normally reported together." Unfortunately, payers often mandate use of modifier 59 in many other situations, resulting in payment denials and resubmissions.

A little history

Consider CPT code 14040, which is used to report local flaps of the face. The introduction to the Adjacent Tissue Transfer section of the CPT book indicates that codes 14000-14302 are to be used for "excision (including lesion) and/or repair by adjacent tissue transfer..." The codes include the excision of cutaneous lesions.

Thus, if a 1.2 cm basal cell carcinoma of the forehead is excised and the defect reconstructed with a rhomboid flap, the procedure is reported with code 14040. To report the basal cell excision (11642) in addition to 14040 is unbundling, as the adjacent tissue transfer codes include skin lesion excision.

However, if a 1 cm basal cell of the cheek is excised (and closed primarily) in addition to a basal cell of the forehead (and rhomboid flap), then two distinct procedures have been performed. Reporting code 11642 for the cheek basal cell excision in addition to code 14040 for the forehead procedure is not unbundling; it is listing two separate procedures.

Prior to 1997, when modifier 59 was introduced in the CPT book, there was no way to report these two procedures without having code 11642 denied by payer computer systems.

Currently, the correct way to report the cheek and forehead procedures is:

14040 Excision of basal cell of forehead with flap reconstruction
11642-59 Excision of basal cell of cheek

Modifier 59 indicates a "separate excision" and "separate lesion." In this case, 14040 and 11642 are procedures "not normally reported together, but are appropriate under the circumstances."

This was the original intent of modifier 59, and is the way CPT instructs the modifier to be used.

Note also that CPT indicates:

(W)hen 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.

Thus, the CPT book specifically instructs coders not to use modifier 59 indiscriminately. Its specific intent is clearly articulated.

Payers expand requirements

As with other situations in CPT coding, the reality of coding and reimbursement often does not correspond with theory, i.e., the instructions in the CPT book. (Recall that since January 2011, one cannot, for Medicare patients, report a consultation code when one performs a consultation. Yes, it's illogical, but Medicare has rules and requirements that are at variance with correct CPT coding.)

Unfortunately, requirements of the use of modifier 59 have been greatly expanded by payers. Moreover, there is inconsistency among payers in the use of modifier 59. This makes it confusing and frustrating to surgeons, as often the requirements demanded by a particular insurance company are only evident when a claim is rejected and must be resubmitted.

Part of the confusion in the payer community lies in the list provided in the descriptor for modifier 59:

"...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..."

This list presents examples of situations where modifier 59 might be used. It is not a requirement that 59 must be used in all these circumstances. Unfortunately, many payers, including Medicare, require the use of 59 in multiple varied circumstances.

Some examples and guidelines

Consider the excision of three benign lesions of the face, each measuring 8 mm. The correct method of coding this procedure, using CPT guidelines, is:

11401 Excision of lesion
11401-51 Excision of lesion
11401-51 Excision of lesion

The 51 modifier indicates that multiple procedures are performed at the same operative session. 

Some payers, including some Medicare fiscal intermediaries, will only reimburse for the first lesion, if the procedures are correctly reported with the multiple procedure modifier, 51. Instead, they require the use of modifier 59 rather than modifier 51 to indicate that the surgeon is not billing three times for the same lesion excision:

11401 Excision of lesion
11401-59 Excision of lesion
11401-59 Excision of lesion

Some payers require the use of both modifiers, even though the CPT book specifically indicates that only one modifier should be used:

11401 Excision of lesion
11401-59-51 Excision of lesion
11401-59-51 Excision of lesion

Consider now a malignant lesion of the hand (excised diameter 12 mm) which is excised and an intermediate repair (3 cm) performed. The correct way to report the procedure, per CPT rules, is:

12042 Intermediate repair
11622-51 Excision of lesion

Some payers will not reimburse for the lesion excision unless modifier 59 is appended:

12042 Intermediate repair
11622-59 Excision of lesion

Unfortunately, these rules are not listed anywhere, and various payers have different requirements. Only after a claim is rejected will the surgeon learn that modifier 59 is required.

Beware of CCI issues

The Correct Coding Initiative (CCI) bundles global CPT codes. In circumstances where codes generally bundled together are used for separate procedures, modifier 59 must be used. Inexplicably, as most surgeons have discovered, CCI overbundles innumerable procedures that are never considered global clinically or by CPT rules.

For example, CCI bundles codes 64721, carpal tunnel release, and 25000, deQuervain's release. Neither of these procedures is, of course, global to the other. These procedures are distinct and are always performed through separate incisions. In order to receive reimbursement, however, when both procedures are performed, modifier 59 must be used:

64721 Carpal tunnel release
25000-59 deQuervain's release

This makes no sense clinically, nor by CPT guidelines, but modifier 59 is required to override a CCI edit of two distinct procedures. Otherwise the deQuervain's release, 25000, will be disallowed.

Don't abuse the modifier

Modifier 59 is not to be used to obtain reimbursement for unbundled procedures. If a procedure is indeed global to another procedure, it is not appropriate to append 59 to the secondary procedure in order to obtain reimbursement. For example, an extensor tendon repair on the dorsum of the hand includes closure of the wound (intermediate repair). To report the repair in addition to the tendon repair is unbundling:

26410 Extensor tendon repair
12041-59 Intermediate repair

Although reporting the repair with the 59 modifier would bypass many insurance computer edits, it is improper coding, i.e., unbundling, and should not be done.

- Dr. Janevicius is the Society's representative to the AMA CPT Advisory Committee.

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