Health Information Management

Tip: Ask these questions before appending modifier -59

APCs Insider, July 8, 2011

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Coders can use a decision tree to ensure they append modifier -59 (distinct procedural service) appropriately.

First, are the codes bundled together based on CPT® or NCCI guidelines? Check the NCCI edits carefully using computer software, the Medicare website, or Medicare manuals. If the codes bundle together, report both without an unbundling modifier. If they do not, proceed to the next question.

Second, is the procedure distinct from other procedures (e.g., different site, session, patient, diagnosis)? If not, bill only the primary service and not the bundled code. If yes, proceed to the next question.

Third, does the NCCI edit have a 0 modifier indicator? This indicator means that you may never bypass the edit regardless of which modifier you append. If the edit has a 0 indicator, do not use modifier -59 and do not bill separately. If it doesn't have a 0 indicator, proceed to the next question.

Finally, can you append a better, more specific modifier than modifier -59? Examples include those that specify side of the body, (i.e., -LT,–RT) and the digit modifiers (e.g., -T1, -T2). If you can append a more specific modifier, use it to bill separately; if not, append modifier -59 to bill separately.

The tip is adapted from “Decision tree helps guide appropriate use of modifier -59” in the June issue of Briefings on APCs.



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