Health Information Management

Don’t use modifier -59 for E/M codes

APCs Insider, March 20, 2009

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Q. Is it appropriate to append E/M codes with a modifier -59 (distinct procedural service)? The edit seems redundant and unnecessary. For example, the CCI edit hits for a code 1/code 2 pair for 99213 (or any level E/M) and 92014 (ophthalmologic exam). Another example is 96402 (chemotherapy administration, subcutaneous or intramuscular, hormonal anti-neoplastic) and 99213 (or any level E/M), and the E/M code is code 2 of the pair.

A. Do not use modifier -59 for E/M codes. In the case of the ophthalmologic exam (92014), the appropriate modifier is -27 (multiple outpatient hospital E/M encounters on the same date) if the service was a separate and distinct E/M service from the office visit. The modifier description focuses on separate departments, for example an office visit at a primary care clinic and an ophthalmologic exam at the eye clinic.

In the case of the chemotherapy service, the appropriate modifier is modifier -25 (significant, separately identifiable E/M service by the same physician on the same date of service) if the visit was significant and separately identifiable from the chemotherapy service. The modifier description focuses on the services being beyond the usual pre-op and post-op care associated with the chemotherapy service.

For more information, review CMS program memorandum A-00-40 and program memorandum A-01-80.

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