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Part B Insider (Multispecialty) Coding Alert


Consider This Expert Advice for Modifier 59 Mastery

Ensure your documentation supports modifier 59 usage.

Before you append modifier 59 (Distinct procedural service), a comprehensive understanding of how and when to use the modifier is critical to avoid denials or worse. It’s a good idea to review coding guidelines and Medicare’s rules, too, before using this popular modifier.

Remember: CMS reminds providers that there must be valid reasons to report a claim with modifier 59.

“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,” cautions CMS.

See CCI Impact on Modifier 59 Choice

The Correct Coding Initiative (CCI) publishes a list of comprehensive/component edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations, experts say. Each edit consists of a column 1 and column 2 code.

When the modifier indicator is “1,” this means that you may be able to report both codes of an edit pair under certain circumstances by using a modifier. For example, you can overcome the edit, if appropriate with the use of a modifier like modifier 59, explains Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Caveat: Just because you can add a modifier, that doesn’t mean you should. Be sure you have the supporting documentation for requesting payment for both codes before adding a modifier to the bundled pair.

“Modifier 59 and other CCI-associated modifiers should not be used to bypass a CCI edit unless the proper criteria for use of the modifier 59 are met,” Falbo adds. “Documentation in the medical record must satisfy the criteria required by any CCI-associated modifier that is used.”

You can use modifier 59 when the surgeon performs the bundled procedures for different anatomic sites/regions, different organs, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ, Falbo explains.

Caution: You should never append modifier 59 to an E/M service.

Don’t miss: Although CCI bundles indicate which CPT® and HCPCS codes you should normally not report together, Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington reminds coders that CCI is more than just a list of codes that bundle together.

“There are general rules for all coding concepts and general rules for each CPT® chapter,” Bucknam says. “Read through these rules and be sure you understand the concepts for the chapters you work in most often. This will help you understand what is likely to bundle and will guide you even if you don’t have software that tells you when you make a bundling error.”

Review This Coding Example

Operative notes indicate that the surgeon performed a 15 sq cm subcutaneous debridement on a patient’s left shin, and an 18 sq cm debridement to the muscle on a patient’s left thigh. In this scenario, you should report 11043 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) for the thigh debridement, along with 11042 (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less) for the shin debridement. Don’t forget to append modifier 59 to 11042 to show that the shin debridement is a separate service from the thigh debridement.

“If the medical record documentation indicates the wounds are in different anatomical sites, and both 11042 and 11043 are properly documented, then 59 is appropriate and should always be appended to the secondary or component code in CCI combination,” explains Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

The X factor: Each year, more payers are switching to the X modifiers; these are a more specific set of modifiers that are meant to replace modifier 59. The X modifiers are:

  • XS (Separate Structure)
  • XE (Separate Encounter)
  • XP (Separate Practitioner)
  • XU (Unusual Non-Overlapping Service)

Tip: If you’re unsure of your payer’s stance on modifier 59 and/or the X modifiers, be sure to check your contract before filing a claim with distinct procedural services.