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Reporting CPT Modifiers 51 and 59

A modifier is used to report or indicate that a performed service or procedure was altered by some specific circumstance and noted by the physician or other qualified health care professional (QHP) but not changed in its definition or code. Modifiers enable health care professionals to effectively respond to payment policy requirements established by Medicare and other third-party payers, and their definitions are listed in Appendix A of the Current Procedural Terminology (CPT) code set.

This article discusses and provides examples of the appropriate use of modifier 51, Multiple Procedures, which is used when multiple procedures (other than evaluation and management [E/M] services, physical medicine and rehabilitation services, or provision of supplies [eg, vaccines]) are performed at the same session by the same individual, and modifier 59, Distinct Procedural Service, which is used when a procedure or service was distinct or independent from other non-E/M services performed on the same day.

Modifiers 25, 51, 59, and 76

Although this article focuses on the use of modifiers 51 and 59, the definitions for modifiers 25 and 76 are provided here as references and for context. Note that additional information on modifier 25 can be found in the March 2023 issue of the CPT Assistant newsletter.

Modifier 51, Multiple Procedures. When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services, or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

Modifier 59, Distinct Procedural Service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. 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.

Modifier 25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines in the CPT code set for instructions on determining the level of E/M service).

The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting E/M services on the same date. This circumstance may be reported by appending modifier 25 to the appropriate level of E/M service code. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery; instead, see modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier 76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.

Differences Between Modifier 51 and Modifier 59

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from another non-E/M procedure or service performed on the same day. Prior to 1996, multiple procedures and/or services were reported with modifier 51 appended to the second and subsequent procedure and/or service code(s) to indicate that the additional procedure and/or service was distinct or independent from another procedure and/or service performed on the same day.

In 1996, the Centers for Medicare & Medicaid Services (CMS) implemented a coding initiative to control improper unbundling of codes for Medicare Part B services. This initiative was based on coding conventions defined in the CPT code set, national and local third-party payer policies, coding guidelines developed by national societies, and standard medical and surgical practices. In 1997, in response to this initiative, the CPT Editorial Panel established new modifier 59 for reporting multiple procedures that are not typically reported together but are appropriate to report together under certain circumstances.

Documentation in the medical record supporting the use of modifier 59 needs to indicate a different session; different procedure or surgery; different site or organ system; separate incision or 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 physician or other QHP. However, when another existing modifier (eg, modifier 76 with CPT code 93286 to designate the evaluation and programming of a device performed both before and after surgery) is appropriate for use, that modifier should be used rather than modifier 59.

Modifier 59 should only be used if it best explains the circumstances and a more descriptive modifier is not available. Note that modifiers 51 and 59 should not be appended to an E/M service, which is specifically noted in their definitions, or to any add-on code (identified with the “+” symbol).

To report a separate and distinct E/M service with a non-E/M service performed on the same date, use modifier 25.

Use of Modifier 59 for Codes With “Separate Procedure” Designation

Some procedures listed in the CPT code set that are typically performed as an integral component of a more comprehensive procedure are identified by the inclusion of the term “separate procedure” in the code descriptor. Any procedure represented by a code designated as a “separate procedure” should not be reported in addition to the code for the more comprehensive procedure or service for which it is considered an integral component.

However, when a procedure that is designated in the CPT code set as a “separate procedure” is performed independently or is considered to be unrelated to or distinct from another procedure performed at the same time, it may be reported by appending modifier 59 to indicate it is not an integral component of the other procedure and is a distinct, independent procedure. Note that third-party payers typically require that modifier 59 to be appended to the code with the lower total relative value unit (RVU); however, for codes with a separate procedure designation, modifier 59 is typically appended to the code that is designated as a separate procedure.

Coding Examples

The following clinical scenarios provide a few examples of the appropriate use of modifiers 51 and 59.

Example 1: Removal of Two Separate Lesions

Scenario

A malignant lesion with an excised diameter (including margins) of 1.5 cm is excised from the left arm, and a second malignant lesion with an excised diameter (including margins) of 2.4 cm is excised separately from the same arm.

How to Report

Code 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm, would be reported for the first excision and code 11603, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm, for the second excision. Modifier 59 would be appended to code 11602 (the lower-valued code) to indicate that a distinct second procedure was performed: in this case, a second lesion was removed. As indicated in the guidelines for Excision—Malignant Lesions in the Integumentary System section, each malignant lesion that is excised should be reported separately.

Example 2: Reporting Multiple Procedures

Scenario

A 35-year-old male presents to the emergency department (ED) after an altercation. The patient sustained multiple injuries, including defensive lacerations to his right arm. A medically appropriate history and physical examination is performed, identifying a 3.0-cm superficial laceration to the right hand and a deep 5.0-cm laceration of the forearm with partial involvement of the muscle fascia. The patient is neurovascularly intact and has normal muscle function, and no foreign bodies are identified. The 3.0-cm hand laceration requires a simple repair. The 5.0-cm forearm laceration requires limited undermining and a layered closure to repair the muscle fascia.

How to Report

Code 12032, Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm, would be reported for repair of the 5.0-cm deep laceration to the right forearm.

Code 12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm, with modifier 59 appended would be reported for repair of the 3.0-cm superficial hand laceration. Modifier 59 is appended to code 12002 to indicate that a distinct procedure was performed on the same extremity on the same date.

Two lacerations at the same anatomical region would normally be reported by summing the lengths. However, in this example, one laceration is a simple repair and the other an intermediate repair; therefore, they are reported separately.

In addition, an appropriate level of E/M service for an ED visit (99281-99285) may be reported with modifier 25 appended if a significant, separately identifiable E/M service was performed on the same date. The significant, separately identifiable E/M service should be defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

Example 3: Use of Modifiers 51 and 25 With Preventive Care and Vaccinations

Scenario

A 12-year-old patient presents for a routine preventive healthcare visit. Her immunization record is reviewed. The physician recommends and counsels the patient about receiving the human papillomavirus (HPV) vaccine and the Pfizer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine. The parent gives their consent for the vaccines.

How to Report

The HPV vaccine administration would be reported with code 90460, Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered, while the Pfizer COVID-19 vaccine administration would be reported with code 0121A, Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; single dose. Reporting two different vaccinations is not considered unbundling; therefore, modifier 51 (instead of modifier 59) would be appended to the lower-valued code (0121A).

The vaccine products would be reported with codes 90651, Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33,45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use, and 91312, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use. Note that modifiers would not be reported with the vaccine product codes.

The preventive healthcare visit would be reported with code 99394, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years), with modifier 25 appended to indicate that a significant, separately identifiable E/M service was performed on the same date.

Example 4: Reporting Multiple Surgical Procedures

Scenario

A patient undergoes suture repair of one section of the colon and a partial colectomy, resection, and anastomosis of a different section of the colon.

How to Report

The colectomy procedure would be reported with code 44140, Colectomy, partial; with anastomosis, and the suture repair in a different section of the colon with code 44604, Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy. Reporting both procedures would be considered unbundling if both procedures were performed at the same site (eg, suturing the anastomosis after resection); therefore, modifier 59 would be appended to the lower-value code (44604) to indicate that the suture repair was performed in a different section of the colon and that it was a distinct service.

Example 5: Reporting Multiple Surgical Procedures

Scenario

A patient cannot be removed from the use of a ventilator after an acute injury. A planned percutaneous tracheostomy and percutaneous endoscopic gastrostomy are performed in the same operative setting.

How to Report

Codes 31600, Tracheostomy, planned (separate procedure), and 43246, Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube, would be reported. These two procedures were not performed in an anatomically related region or through the same skin incision; therefore, reporting both codes would not be considered unbundling. Note that some third-party payers may still require modifier 59 to be appended to code 31600 to indicate that the separate procedure performed was a distinct and separate procedure from the gastrostomy tube placement.

Example 6: Reporting Multiple Surgical Procedures with Modifier 51

Scenario

A patient is admitted for removal of their gallbladder and appendix. Both are removed during the same operative session.

How to Report

Codes 47562, Laparoscopy, surgical; cholecystectomy, and 44970, Laparoscopy, surgical, appendectomy, would be reported. Modifier 51 would be appended to the appendectomy code to indicate that multiple distinct procedures were performed during the same session.

Summary

The key points for reporting modifiers 51 and 59 are summarized as follows:

Modifiers 51 and 59 should not be appended to E/M codes, physical medicine and rehabilitation codes, or provision of supplies (eg, vaccine products).
Modifier 59 is reported instead of modifier 51 when two procedures or services may be reported together in defined circumstances that are not considered unbundling of a more comprehensive procedure.
Modifier 51 is reported instead of modifier 59 when two procedures or services are not considered unbundling and do not have a restriction for being reported by the same health care professional during the same session.
Modifiers 51 and 59 are appended only when another more descriptive modifier (eg, use of modifier 76) is not available.
Modifiers 51 and 59 are typically appended to the code with the lower total RVU, unless the code descriptor includes the term “separate procedure,” in which case modifier 59 is appended to the code that is designated as a “separate procedure.”
Third-party payers’ reporting guidelines for these modifiers may vary from CPT reporting guidelines. Check with individual third-party payers to determine their guidelines for the use of these modifiers.