Modifier 59

Modifier 59 means Distinct Procedural service and this modifier is appended with appropriate procedure code to indicate to the insurance company, that the services performed were distinct or independent from other non E/M services performed on the same day/session.

Usage of modifier 59 with examples:

1. Radiology

Modifier 59 should be appended when physician performed the radiological examination twice (under two different sessions) on the same day, on the same region but different views.

Example:

Right elbow 3 views – 73080-RT (Radiological examination, elbow; 3 views)

Right elbow 2 views – 73070-RT (Radiological examination, elbow; 2 views)

In the above example: The radiological examination done on the same day, on the same region but different views (different procedure codes), so in this case we should not supposed to append modifier 77 or 76 modifier as it’s a different procedure codes.

If we submit the claim without modifier, then the insurance company will pay the CPT 73080(which has more views) and they will deny the CPT 73070 as duplicate (As why they require 2 views when they have already performed 3 views).

In this case how we will get paid both the procedure code 73080 and 73070, because this is done under 2 different sessions on the same day.

In order to reimburse the above CPT code 73080 and 73070 we will append the modifier 59

73080

73070 with modifier 59

Now the insurance will identify the above procedure as distinguish procedure codes and reimburse both procedure codes.

 

2. Ultrasound obstetrical:

Example 1: Please see the procedure code 76816 in the Current procedural Terminology book:

76816 – Ultrasound, pregnant uterus, real time with image documentation, follow up, per fetus

Under the procedure code 76816 the parenthetical message states “report 76816 with modifier 59 for each additional fetus inspected in a multiple pregnancy”.

It means in ultrasound obstetrical follow up. If it’s more than one fetus, then the second and any additional fetuses should be reported separately by code 76816 with modifier 59 appended.

If it is only one fetus we report the claim with only one procedure code:

76816

1. If it’s two fetuses, we report the claim as follows:

76816

76816 with modifier 59

1. If three fetuses, we report the claim as:

76816

76816 with modifier 59

76816 with modifier 59

 

Example 2: Please see the procedure codes 76818

If one fetal biophysical profile assessment with non-stress testing, then we code only

76818

• If it’s two fetuses biophysical profile assessment with non-stress testing, then we code

76818

76818 with modifier 59

 

3. Integumentary system

A) Debridement

When debridement of multiple wounds performed, sum the surface area of those wounds that are at the same depth.

But if the multiple wounds with different depths on the same day, then we should not combine the surface area and report the code. In this case we should report the code separately by using a modifier 59.

Depths of skin:

1. Epidermis
2. Dermis
3. Subcutaneous
4. Muscle
5. Fascia
6. Bone

Let us see example:

Example 1:

Assume below wounds are debrided on the same day.

Bone debrided with 8 Sq. cm to heel ulcer and 12 Sq. cm to heel ischia ulcer, in this case we can add the surface area as the depth is same and report the code.

Answer: CPT 11044

Example 2:

Suppose Bone debrided with 8 sq cm to heel ulcer and subcutaneous tissue debrided with 10 sq cm to heel abdominal wound.

In this case we can’t add, because the bone and subcutaneous are different depths. As stated earlier, we code separately with modifier 59 to distinguish as different procedure.

Answer: CPT 11044 and CPT 11042 with modifier 59.

 

B) Repair codes:

We need to append modifier 59, when we have more than one classification of wounds is repaired (different groups of anatomic sites).

Before going to example the hierarchy of the repair codes is as follows:

Complex repair>>>>Intermediate repair>>>>Simple repair

Here more complicated is primary procedure code and less complicated is secondary procedure. This secondary procedure should be reported by appending modifier 59.

Assume multiple repairs, simple and intermediate performed on the patient on the same day.

In this case we will code both intermediate procedure as well as simple repair code procedure, but we need to append modifier 59 to simple repair codes.

Example:

Simple repair of 2.5 cm laceration on right elbow, simple repair of 5.6 cm laceration on right thigh, intermediate repair of 2.3 cm laceration on right hand and complex repair of 7.2 cm laceration on right forearm services were performed on patient on the same day.

• In the above example 2.5 cm laceration of right elbow and 5.6 cm laceration of right thigh is under same anatomy group and repair i.e. simple. So we should add to report the code.
  • cm + 5.6 cm = 8.1 cm.

Report with CPT 12004

• Intermediate repair of 2.3 cm laceration on right hand

Report with CPT 12041

• Complex repaid of 7.2 cm laceration on right forearm

Report with CPT 13121

We should report the codes as follows:

13121,

12041 * 59 and

12004 * 59

 

4. Anesthesia

When Anesthesiologist performs both general anesthesia and pain management, then we have to code both general anesthesia and pain management procedures. But pain management procedure should be reported by appending modifier 59.