Health Information Management

Tip: Identify appropriate situations to use modifier -59

APCs Insider, July 1, 2011

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Coders use modifier -59 (distinct procedural service) to identify instances in which overriding an NCCI edit is appropriate because of certain circumstances. Those circumstances include:

  • Different session or patient encounter
  • Different procedure or surgery
  • Different site or organ system
  • Separate incision/excision
  • Separate lesion
  • Separate injury (or area of injury in extensive injuries)

For example, a patient comes into the outpatient setting with benign lesions on her face, hand, and back. The physician biopsies the lesion on the patient’s hand, then biopsies and removes the lesions on her back and face. For the hand lesion, code the biopsy since that is all the physician performed. For the face and back lesions, code only the removal of these lesions because the biopsy is a natural part of the removal

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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