Background
Under certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services and CPT® modifier 59 may be appropriate depending on the circumstances. CPT® modifier 59 is used to identify procedures/services that are not normally reported together and this includes the following procedures/services that are not ordinarily encountered or performed on the same day by the same physician:
Session or patient encounter
Procedure or surgery
Site or organ system
Incision/excision
Lesion
Injury (or area of injury in extensive injuries)
When another already established modifier is appropriate, it should be used rather than CPT® modifier 59. CPT® modifier 59 is an important National Correct Coding Initiative (NCCI) associated modifier that is often used incorrectly and it should only be used if no more descriptive modifier is available or when its use best explains the circumstances.
For the NCCI, the primary purpose of CPT® modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.
NCCI edits define when two procedure HCPCS/CPT® codes may not be reported together except under special circumstances.
If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at:
- Different patient encounters
The Part B MAC claim processing system utilizes NCCI-associated modifiers to allow payment of both codes of an edit.
CPT® modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
One of the misuses of CPT® modifier 59 is related to the portion of the definition of CPT® modifier 59 allowing its use to describe 'different procedure or surgery.' The code descriptors of the two codes of a code pair edit usually represent different procedures or surgeries. The related NCCI edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use CPT® modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, CPT® modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.
Use of CPT® modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT® coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of CPT® modifier 59. The HCPCS/CPT® codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.
From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitutes a single anatomic site.
Examples of CPT® Modifier 59 Usage
The following are some examples developed to help guide physicians and providers on the proper use of CPT® modifier 59:
Example 1: Column 1 Code/Column 2 CPT® Code 45385/45380
- CPT® code 45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
- CPT® code 45380 - Colonoscopy, flexible; with biopsy, single or multiple
Policy: More extensive procedure
CPT® modifier 59 is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.
