How Best to Use Modifier 59 (2024)

The National Correct Coding Initiative (NCCI) maintains a list of procedures that are “bundled” and therefore cannot be billed at the same date and time. In some circ*mstances the two procedures can never be paid with one another under any circ*mstance, whereas in other cases the two procedures can be paid together if certain unique circ*mstances exist. Modifiers are used to help communicate these unique circ*mstances and are necessary to bypass the NCCI edits. Commonly used modifiers to communicate these unique circ*mstances include Modifier 58 (staged procedure within the global period), Modifier 59 (distinct procedural service), Modifier 76 (repeat procedure), Modifier 78 (subsequent or related procedure/ service within a global, unplanned return to the operating room), and Modifier 79 (unrelated procedure/ service by the same provider within the global period).

Modifier 59 is an important modifier used for a variety of circ*mstances; however, it is often thought to be applied incorrectly to bypass the NCCI edits. To reduce the error rate, on August 15, 2014, the Center for Medicare and Medicaid Services released Change Request 8863, which established four new subsets of Healthcare Common Procedure Coding System modifiers to define subsets of Modifier 59 (distinct procedural service), with an implementation date of January 5, 2015 (http://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf). The four new modifiers are as follows:

XE: Separate Encounter, a service that is distinct because it occurred during a separate encounter. (This modifier should only be used to describe separate encounters on the same date of service.)

XS: Separate Structure, a service that is distinct because it was performed on a separate organ/structure.

XP: Separate Practitioner, a service that is distinct because it was performed by a different practitioner.

XU: Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

With these four new modifiers/subsets of Modifier 59, how do we best use them in 2015 and beyond, and does this help us understand what is billable together under certain circ*mstances and what is not? On one hand, these four new modifiers/subsets of Modifier 59 help us to better define how to properly use Modifier 59; on the other hand, they may also create confusion. The exact use of these modifiers remains undefined, as ultimately the use of any modifier remains the decision of the individual contractor’s interpretation. Not all contractors have yet stated if or when these new modifiers will be used; in addition, Modifier 59 was not eliminated and may still be used. Furthermore, several contractors had previously instructed their members to use or consider using Modifier 76 in many or all situations in lieu of Modifier 59 due to the aforementioned difficulties with Modifier 59, including Noridian Healthcare Solutions (www.noridianmedicare.com/partb/claims/alerts/082313.html), WPS Medicare Health Insurance (www.wpsmedicare.com/j5macpartb/resources/modifiers/modifiers59and76.shtml), and Cahaba Government Benefit Administrators (http://www.cahabagba.com/news/changes-to-modifier-59-importantnotice/). Even more confusing is that the WPS Web site indicates that Modifier 76 should not be used on surgical procedure codes.

Definitions

Modifier 59 describes a distinct procedural service, and is used to identify procedures and services that are not normally reported together. For example, Modifier 59 should be used when coding for a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion (noncontiguous lesions in different anatomic regions of the same organ), or separate injury. Modifier 59 should not be used on Evaluation and Management Codes, and should only be used when no other modifier is accurate. Although it does not require a different diagnosis for each coded procedure, a different diagnosis also does not necessarily justify the use of the modifier. Modifier 59 should not be used (as it is unnecessary) if the narrative description of the two codes is different. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially. Modifier 59 can be used if a diagnostic procedure becomes the basis for performing a therapeutic procedure, if the information obtained clearly provides the information to perform the procedure, but should not be used if the diagnostic procedure is part of the therapeutic procedure, or constitutes complexity of the procedure.

Conclusions

Although there is not yet any specific consensus on their use, the four new Modifiers may help define distinct billable or repeat services. However, it is important to check with your own local carrier for their rules with regard to which modifiers they accept and under which circ*mstances. As always, bills should only be submitted for legitimately billable services.