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Coding tip: Use modifier -59 accurately to avoid an unwanted audit

Ambulatory Surgery Reimbursement Update, July 24, 2007

Use modifier -59 to indicate that the physician performed a procedure or service which was distinct or independent from other services performed on the same day. Also use modifier -59 to indicate that the physician performed two procedures that are not normally reported together.

Modifier -59 represents:

  • A different session, surgery, or site
  • A separate incision/excision
  • A separate organ
  • A separate lesion, or injury not ordinarily encountered or performed on the same day by the same physician

Using modifier -59 to indicate a different procedure or surgery does not require a different diagnosis and that is also not an adequate criterion to use modifier -59.

From an NCCI perspective, the definition of a "different anatomic site" includes different organs or a different lesion in the same organ. You would not use modifier -59 like modifier -51 on physician claims to indicate that another/additional procedure was performed.

Never use modifier -59 on the first code billed on a claim form. If you overuse or misuse modifier -59, you can cause unwanted payer audits.

This tip is brought to you by Ellis Medical Consulting, Inc.