Podiatry is one of the most highly audited medical specialties. One of the issues that has raised the interest of the Office of Inspector General of the Department of Health and Human Services is using the 59 modifier in an appropriate fashion, thus it is imperative to understand how to use the 59 modifier correctly.
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.
Documentation must support a different session, different surgery or procedure, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
However, when another established modifier is appropriate it should be used rather than modifier 59. Thus, the physician or his/her designated appointee, the biller or the coder need to perform a modifier search to determine whether or not there is another modifier that should be used in lieu of the 59 modifier. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. In reality, modifier 59 is not the modifier of first choice, rather it is the modifier of last resort.
How does CMS know whether or not the 59 modifier is being used correctly? They have software that determines this fact. There is a “Four Bullet Punch List” that determines whether or not the 59 modifier was used correctly. Anytime the use of the 59 modifier is contemplated, one must apply the CPT code in question to each of the “Four Bullets.” If it passes four out of four, it is appropriate to append the 59 modifier to that CPT code.
THE “FOUR BULLET PUNCH LIST” FOR THE CORRECT USE OF THE 59 MODIFIER:
1. The 59 modifier is ONLY used on a procedure code, NEVER on an E/M code.
2. The procedure code in question is a DISTINCT or SEPARATE service from the other services performed on the SAME DAY.
3. The 59 modifier serves as an anatomical modifier. Why?
Because there is not available a true anatomical modifier to show the carrier that the procedure code in question is a separate service from the other services performed on the same day.
4. The 59 modifier is a multiple procedure modifier.
There have to be at least 2 procedures performed.
The 59 modifier is appended to the second procedure based upon how they are listed in the CCI edits.
Don’t “hedge your bets” by placing the 59 modifier on All of the CPT codes that you are billing that day. This is highly inappropriate.
Michael G. Warshaw, DPM, CPC, DABMSP
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