Modifier 59 – Are You Using It Correctly?

Did you know one of the main reasons for claim denials and revenue loss is the incorrect usage of modifiers?Undoubtedly, medical bills are being claimed in a combination of codes for the services performed in the medical practice. But that is not all required. The accurate coding of such corresponding treatment modifiers is mandatory to ensure the reimbursement of these claims, including Modifier 59 (Distinct Procedural Service). In fact, the claim form also needs to have diagnosis codes along with proper ICD 10 codes.

If you are wondering why, you should be concerned about whether you are using Modifier 59 correctly, the reason is that it is one of the most misused modifiers. Unfortunately, you would not be alone and lose your revenue for the failure to use Modifier 59 correctly.

What Is Modifier 59 Used For?

Typically, Modifier 59 indicates that more than one procedure is performed on the patient in a single visit. But such procedures should be on the different part of the bodies.

However, at times, it is used to bypass the edit system of the insurance carrier and avoid being bundled with another service on the same claim.

Going by the guidelines, it should never prevent a service from getting bundled with the other.

Modifier 59 is developed to indicate a physician’s service on the patient during the same visit whereby the procedures are independent of each other. Such modifier helps in reporting the services usually performed together, but it can be done under certain circumstances, as deemed fit by the physician. 

Are You Adding Modifier 59 Correctly?

As a claimant, you must be aware that Modifier 59 is used correctly with other modifiers. For instance, you cannot include Modifier 59 with Modifier 76. Thereby, your claim will get rejected altogether.

The reason is that Modifier 76 is used for stating the same procedure being performed on the patient multiple times on the same day by the same physician after the initial consultation.

Whereas Modifier 59 indicates different sessions, surgery/procedure, different site/organ, incision or excision, injury treated that were not part of the previously reported procedure. The same physician does these other procedures on the same day after performing the initial procedure scheduled for.

The physician also performs the unscheduled procedure during the treatment because he deems fit for the betterment of the patient.

Are You Using Modifier 59 Indiscriminately?

The National Correct Coding Initiative (NCCI) promotes the usage of correct coding and prevents improper payment often leading to the conduct of audits. However, to bypass the NCCI edits, the practices often misuse the modifiers.

Whether it is done by purpose or mistake, a practitioner has to be mindful of not using Modifier 59 indiscriminately.

Undoubtedly, the practices append modifier 59 to a diagnostic procedure performed following a therapeutic procedure. However, when the diagnostic service is part of the therapeutic procedure, the modifier is used arbitrarily.

Who Can Use The Modifier?

In a practice, one needs to be aware that only a coder or provider of the service who has access to the patient’s chart can add the modifier 59. It can never be used by the biller, even when the biller knows that without the modifier will result in claim rejection or bundling.

You have to go back to the service provider when you believe Modifier 59 is omitted from the claim as a biller. You should always have substantial evidence to get back the Modifier 59 claim.

What Are The Guidelines For Using Modifier 59?

You can easily find the guidelines for using Modifier 59 in detail at the Medical Learning Network.

But the basic principles of the Modifier 59 are:

  • For appending Modifier 59, new diagnosis is to be made
  • A new diagnosis does not qualify for Modifier 59 if new treatment does not follow
  • The modifier should not be used to bypass the edit when the above criteria fail to meet
  • In the NCCO table, in Column 2 code, Modifier 59 should be appended
  • It is not a management or evaluation modifier
  • Every documentation needs to be done clearly by the physician for Modifier 59
  • Just because the software asks you to add Modifier 59, don’t add it. Instead, one must read the documentation in detail to ensure whether it should be added or not.

Use the Modifier 59 Correctly – Get the Timely Claims!

The improper use of a modifier is not limited only to Modifier 59. In fact, the practices often use other modifiers inappropriately such as 24, 25, 50, 51, and 76. These modifier coding mistakes can easily be avoided when it is being done by a professional medical billing company such as 24/7 Medical Billing Services. This is one of the best alternatives, i.e., to connect with experts who are well-trained in the medical coding and stays at the top of the changes done into this coding system, so that your claims will never fail or come under audit because of overbilling.

Read more: Top 5 Mistakes With Medical Coding Services

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