When to use CPT Code Modifier 59

Modifier 59 is denoted for coding two procedures which look similar but differ in some or the other way. Whenever we get any situation where two CPT codes overlap each other or include some part of the procedure, in such condition we have to use CPT modifier 59 along with one of the CPT code. When I began learning about modifiers, they were very difficult to apply while coding medical reports. It might be a two digit number, but we have to see a whole lot of story while using these CPT code modifiers. Now, Since we are here to learn about CPT modifier 59, we will first check the description of this modifier in the codebook.

Modifier 59 – Distinct Procedural Service

Now, to decide when to use the CPT modifier 59, you need to first check the NCCI edits before using this modifier. If you go with the definition of modifier 59, it says the modifier indicates a procedure or service that was distinct or independent from other services performed on the same day. This modifier identifies the procedures which are not allowed to be reported together without a cpt code modifier. 

Read also: Superb tips for coding modifier 58, 78 and 79

Use of NCCI edits for CPT Modifier 59

Their are certain criteria in NCCI (National Correct Coding Initiative) edits where you will come to know the use of modifier 59. You cannot go blindly if you see an NCCI edit between two or more CPT codes. Their can be two scenarios in which NCCI edit will show its edits for the coded procedures.

1. One minor procedure may be included completely in the major or comprehensive procedure (Indicator 0)
2. The CPT codes can be mutually exclusive to each other (Indicator 1)

Now their are two Correct Coding Modifier Indicator (CCMI) indicators (0 and 1) for Column 1 and Column two CPT codes in Medicare NCCI edit list.  Now, here if the indicator is “0” the two codes of both the column should not be coded together by the same provider for the same beneficiary on the same date of service. And if the indicator is “1” the two codes of both the column can be coded together only if you are assigned with appropriate NCCI associated modifiers.

Read also: Best coding guide for Modifier 22, 23, 24 and 25

X{EPSU} modifiers along with CPT Modifier 59

CPT code Modifier 59 is used frequently in diagnostic and surgical procedure codes. Now we have X{ESPU} modifiers to be used to give more specific information about overlapping procedures.  Modifier 59 used to give very less specific information about the overlapping procedures, hence the new X- modifiers will now be used for specificity in the distinction of two or more procedure or cpt codes. Let us check the X modifiers which will be used to give more specific information in place of  modifier 59 . For example, in future if we come across one view of chest x ray 71045 with two view of chest x ray 71046 on same day we have to use any one modifier below to bill both the cpt codes in the profession of medical coding.

–XE: Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

-XS: Separate Structure, A Service That is Distinct Because It Was Performed On A Separate Organ/Structure

-XP: Separate Practitioner, A Service That is Distinct Because It Was Performed By A Different Practitioner

–XU: Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

The new codes along with CPT modifier 59 are removing lot of confusion in coding. Medical coder should be perfect in coding these new modifiers along with CPT codes. Do follow all the coding guidelines and use the appropriate modifier along with procedure codes. Any misuse of modifier will lead to fraud, hence the coders should be more careful while using these modifiers.