Secret Tips of Using 59 modifier

Basic about 59 modifier

Modifiers should be added to CPT codes when they are required to more accurately describe a procedure performed or service rendered. Medical billers generally have problem with using modifiers. Modifier 59 is the most confusing modifier out of all the modifiers. It is one the most commonly misused modifier as well. The most common scenario when it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. But, many times, it is used to prevent a service from getting bundled with another service. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system. It should be used only when no suitable modifier is present other than 59 modifiers. If some another modifier accurately describes the procedure, we should use that modifier instead of 59 modifier. In 2015 we have new modifiers used in place of 59 for more specific information.

Secret Tips Using 59 modifier

Rules for using 59 modifier

CPT Manual defines modifier 59, as a “Distinct Procedural Service.” .There are certain modifier indicators, which helps us using 59 modifiers. The NCCI edit includes these modifier indicators 0, 1 and 9. Following are the things to follow with these modifiers:
0: No modifier allowed under any circumstance; the code pair will not be paid separately
1: Modifier -59 is allowed in order to differentiate between services provided; allows for separate    payment when used correctly
9: No modifier needed as the edit is inactive as of the posted date and services may be separately billable

Things to check before using 59 modifier

The documentation in the medical report should clearly tell that the procedures where done on different anatomic site for using 59 modifier.
The modifier indicator or CCI edit should be properly checked before using 59 modifier.
Always add the modifier to the CPT with less dollar value (RVU) to avoid denial of claims.
Many times, we have to use 59 modifier with same CPT codes, denoting they should be paid because they are done separately on different anatomic site. We have many scenarios of using 59 modifier but we never think of when to avoid using 59 modifier. Here are many instances where medical coders tend to do make errors using 59 modifier. There are few procedure or CPT codes, which are included with major procedure codes; hence, they should not be separately billable.

Let us checkout few CPT or procedure code which should be billed with 59 modifier when coded with major procedures. In radiology, we have many examples where we should avoid using 59 modifier. The first and the foremost CPT codes are 74230 and 74220. Cpt Code 74220 is assign for Barium Swallow studies and CPT code 74230 is assigned for Modified Barium swallow studies.
74220 – Barium Swallow
74230 – Modified barium Swallow
Modified Barium Swallow studies always include Barium Swallow study. Therefore, whenever these two procedures are performed on same day, we should only bill 74230 Modified Barium Swallow. Procedure 74230 is a major exam, which include 74220 CPT code. Hence, in future never use a 59 modifier with 74220 along with 74230 when performed on same day. This is a very common error among coders in Radiology coding.

Same CPT codes with 59 modifier

This is also a very frequent error while coding procedure codes in vascular family. If a coder fails to understand the guidelines, there are many error occurred in vascular coding. Selective and Non-selective catheteritization concept should be understood clearly. Many times coder tends to code a third order artery CPT Code 36247 along with 36245 a first coder artery within a same vascular family. If we are studying a vascular family with a same access, we have to code only the highest artery studied, lower order arteries gets included in the highest order CPT code. So, if a third order artery studied in lower extremity 36247 it will include first order 36245 and second order 36246 arteries within a same vascular family with same access. Never use a 59 modifier along with lower order arteries when a higher order artery is studied.

In above scenario, the proper use of 59 modifier will be when the procedure or exam is performed on different vascular family (anatomic site). So, we can assign 59 modifier to distinct them from each other. Here, for example below

When the exam is performed on first order arteries of different vascular families of lower extremity, the CPT codes will be 36245, 36245-59

When the exam is performed on second order and first order arteries of different vascular families in lower extremity, the cpt codes will be 36246, 36245-59

When the exam is performed on third order, second order and first order of three different vascular families of lower extremity, the codes will be 36247, 36246-59, and 36245-59. 
Hope, you all have now the clear picture about modifier 59. Do share the article if you like it.

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