The Power of the 59 Modifier

Nokomis Health | Modifier 59

Do you know how much power there is in a single two-digit number? Most payors and health plans don’t realize the impact that the 59 modifier can have on claim costs. Adding this simple modifier to a CPT code allows that code to bypass several code edits, resulting in erroneous and often incorrect payments. Providers have learned that the way to avoid denials is to append a 59 modifier to many codes. The problem is that in many instances, the modifier is not appropriate.

The 59 modifier is used to designate that a procedure code (CPT or HCPCS code) is a “distinct procedural service” from another code reported either on the same claim or on another claim. According to CMS, “modifier 59 is an important NCCI-associated modifier that is often used incorrectly.1” The CPT manual defines modifier 59 as follows:

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. 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.2

Providers often attempt to charge for two or more CPT codes when they should only charge for one code. For example, a surgeon may charge for arthroscopic debridement of the shoulder (CPT 29822 or 29823) in addition to an arthroscopic rotator cuff repair (29827); however, the debridement is considered to be inclusive to the rotator cuff repair when performed on the same shoulder and should not be separately charged. If there is no 59 modifier on the arthroscopic debridement code, most payors will deny the debridement code according to National Correct Coding Initiative (NCCI) coding rules. But if the payor sees the 59 modifier on the debridement code, the NCCI rules are bypassed and the claim line is typically allowed, resulting in an overpayment to the surgeon.

According to chapter IV.H.22 of the National Correct Coding Initiative Policy Manual for Medicare Services, “CMS considers the shoulder to be a single anatomic structure. An NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder procedures should never be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder. This type of edit may be bypassed only if the two procedures are performed on contralateral shoulders.”

Providers should only use the 59 modifier when the clinical documentation supports the separate, distinct procedural service, and they should be able to support its use by sending the procedure report to the payor upon request. Payors, for their part, need to carefully review all claims that contain a 59 modifier and request records when it is appropriate to do so. Unless payors use discretion in adjudicating claims with the 59 modifier, they are most certainly paying more than they should.

I recently attended a coding conference in which the 59 modifier was discussed. The speaker related a story about visiting one of her clients, which was a surgeon’s office. The surgeon was proud of his new biller because she had been having such great success getting so many claims paid without any denials. The consultant talked to the biller, who said, “all I do is add the 59 modifier to everything and the claims sail right through.” Many clinics take that exact same approach and just add the modifier to claims to get them paid – but they can and should do that only when the procedure is separate and distinct, which is not all that frequent.

Bottom line: the 59 modifier has a lot of power. It is often used incorrectly, and many payors don’t know that they need to carefully scrutinize every claim line that has the 59 modifier on it – otherwise the payor will end up paying more than it should to providers.

Nokomis provides a full suite of claim review and payment integrity services. Our highly skilled, experienced coders and analysts, along with our powerful ClaimWiseTM review engine, identify claim errors that others typically miss, resulting in sustained savings. To learn more about how we can help you with monitoring the 59 modifier, as well as ensuring that all of your claims are paid correctly, contact us for a free claim review.