Physicians, coders and carriers often have trouble distinguishing between modifiers -59 (Distinct procedural service) and -51 (Multiple procedures) because they have similar applications. But a quick review of coding guidelines and as a last resort, a well-placed call to the insurer can help you choose between the modifiers with confidence.
Use -59 to Unbundle
According to CPT, you may append modifier -59 in any of five situations: procedures performed at different sessions or encounters, different sites or organ systems, separate incisions/excisions, separate lesions, or separate injuries (or areas of injury). Note that "separate" can indicate an independent diagnosis linked to the procedure to which you have appended modifier -59, but not necessarily so.
Tammy Boyer, CPC, coding and compliance administrator at a Burlington, Iowa, surgical practice, refers to her national Correct Coding Initiative (CCI) listing to determine whether modifier -59 should be added to a procedure code. "If the procedures I want to report together are bundled and the code I want to use has a '1' next to it in CCI, I use modifier -59 with the code, as long as the situation meets one of the five CPT requirements [listed above]."
Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code. Note that only CCI edits with a status indicator of "1" may be reported using modifier -59. You may not unbundle code combinations with a status indicator of "0" under any circumstances.
For instance, the surgeon performs a lumbar decompression followed by a lumbar microdiskectomy at a different level. Each procedure is associated with a different diagnosis. The coder may report 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) and 63030 (Laminectomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) at the same time. CCI bundles these procedures, but the edit includes a "1" indicator. Therefore, you may append modifier -59 to the microdiskectomy "to differentiate between the services provided" at different times or (as in this case) at different locations on the body. But if the surgeon extends the laminectomy to remove a disk at the adjacent level, you may not append modifier -59 because the procedure is not occurring at a separate anatomical area.
Modifier -59 should not lead to a reduction in reimbursement, but keep in mind that you should not use modifier -59 indiscriminately to increase payments or "protest" CCI coding edits. Because of its ability to unbundle CCI edits and increase payments, payers [...]