Use Modifier 59 correctly to avoid unsuspected danger. Many coders rely on computer software edits for coding guidance but these software edits are only as effective as the way they were programmed. As a coder it is important to understand why the edits were programmed and to not be afraid to follow the company policy to request a correction to an edit that has been programmed wrong.
- CMS created NCCI edits to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS has published, on their website, the NCCI Policy Manual for Medicare Services, which is updated annually in January, and the procedure-to-procedure (PTP) edits, which are updated quarterly. There are two links for physician coding and two links for hospital coding.
- The NCCI edits are in an excel format with code combinations. Each code combination will have either an indicator of ?0,? which means a modifier is not allowed; ?1? a modifier is allowed; or, ?9? not applicable. When a code combination has an indicator of ?1,? and the criteria was met to support modifier 59Distinct procedural service, the modifier is appended to the CPT(R) code in column 2. If the indicator is a ?0,? it is not appropriate to code the two CPT(R) codes together. These codes are not meant to be paid separately, even if the CPT(R) code in column 2 is reported with a modifier 59.
Modifier 59 is appropriate when one of the following criteria is met and documented in the medical record.
Documentation must support:
- A different session,
- Different procedure or surgery,
- Different site or organ system,
- Separate incision/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.
Neither modifier 59 nor the subset of X{EPSU} modifiers should be appended simply to bypass the NCCI edit.
Modifier 59 often is referred to the modifier of ?last resort.? It should be used when no other modifier is appropriate. Also the subset of modifier 59; modifiers X{EPSU}, which follow the same guidelines should not be forgotten. Medicare created these modifiers effective January 1. 2015 and most insurance companies are also accepting them.
- XE Separate Encounter
- XP Separate Practitioner
- XS Separate Structure
- XU Unusual Non-overlapping Service