Modifiers provide additional information about CPT® codes submitted and services rendered without changing the definition of the procedure code itself. Modifiers 51 and 59 are both used when multiple services are performed during a single encounter, but they serve different purposes. This Timely Topic covers the differences between these two modifiers.
Modifier 51 Multiple Procedures
Modifier 51 Multiple Procedures indicates that multiple procedures were performed at the same session. It applies to:
Different procedures performed at the same session
A single procedure performed multiple times at different sites
A single procedure performed multiple times at the same site
Modifier 51 comes into play only when two or more procedures are performed. It is not to be used when a procedure is performed along with an Evaluation and Management (E/M) service.
There are instances where multiple procedures are performed but modifier 51 is not appropriate. Modifier 51 is not appended to add-on codes. For example, modifier 51 would not be appended to CPT code 64462 as it is an add-on code and would be used for any additional injection sites per its definition.
Paravertebral block (PVB), (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
+64462
Paravertebral block (PVB), (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure
Certain codes are designated as Modifier 51 exempt. They are noted in CPT with the symbol and are also listed in CPT’s Appendix E. Codes on this list that are most relevant to anesthesiology practices are:
31500
Intubation, endotracheal, emergency procedure
36620
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous
93503
Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes
Modifier 51 impacts payment. Many payers will apply a multiple procedure reduction to each additional procedure after the first reported code so be sure to list the most complex procedure first on your claims and append the modifier to any additional services reported when the situation calls for use of modifier 51.
Modifier 59 Distinct Procedural Service
Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
Different session or encounter on the same date of service
Different procedure distinct from the first procedure
Different anatomic site
Separate incision, excision, injury or body part
While modifier 51 and 59 both apply to additional procedures performed on the same date of service as the primary procedure, modifier 51 differs from modifier 59 in that it applies to procedures that may be more commonly expected to be performed during the same session.
Like modifier 51, modifier 59 should not be applied to an E/M service. Modifier 25 is used to denote a significantly separately identifiable E/M service. Like modifier 51, modifier 59 also has payment implications. Modifier 51 impacts the payment amount, and modifier 59 affects whether the service will be paid at all.
Modifier 59 is typically used to override National Correct Coding Initiative (NCCI) Edits. NCCI edits include a status indicator of 0, 1, or 9. A status indicator 1 identifies those code pairs not normally payable on the same date of service but may be paid in some circ*mstances when reported with an appropriate modifier (often modifier 59) and supported by documentation that demonstrates why the edit is not applicable and payment is warranted.For example, the modifier may be used when reporting anesthesia care and a post-operative pain procedure when the procedure meets the criteria that allows for it to be separately reportable. A previous Timely Topic gives additional examples of applying modifier 59 to anesthesia services.
CPT instruction also tells us that modifier 59 should not be used when a more appropriate modifier is available. For example, if a procedure is performed bilaterally, modifier 50 would be the more appropriate modifier.
Modifiers XE, XP, XS and XU became effective in January 2015 and were developed to provide more specific reporting in circ*mstances where modifier 59 may be used. At this time, these modifiers are not required but may be used instead of modifier 59 when appropriate to the clinical scenario being billed.
XE
Separate encounter, a service that is distinct because it occurred during a separate encounter
XP
Separate encounter, a service that is distinct because it occurred during a separate encounter
XS
Separate Structure, a service that is distinct because it was performed on a separate organ/structure
XU
Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
It is important to understand correct coding and modifier usage to ensure appropriate payment for your services. As always, make sure you are familiar with instruction from your local carriers and ensure your documentation supports what and how you report your services.
The following is a quick reference to summarize when to use modifier 51 and 59:
Modifier 51: Multiple Procedures
Modifier 59: Distinct Procedural Service
additional procedure /same session same procedure/multiple times same procedure/different site
distinct procedure/different encounter distinct procedure/different provider distinct procedure/different site do not use if another modifier is applicable
Modifier 51 impacts the payment amount, and modifier 59 affects whether the service will be paid at all. Modifier 59 is typically used to override National Correct Coding Initiative
National Correct Coding Initiative
The National Correct Coding Initiative (NCCI) is a Centers for Medicare & Medicaid Services (CMS) program designed to prevent improper payment of procedures that should not be submitted together.
CPT guidelines explain the 51 modifier should apply when “multiple procedures, other than E/M services, are performed at the same session by the same individual. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).”
Modifier -51 would be attached because the biopsy is the lesser-valued procedure done at the same session, and modifier -59 would be attached to indicate that the biopsy, which is normally bundled with excision of the same lesion, was done on a separate lesion from the one that was excised.
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.
Never use both modifier 51 and 59 on a single procedure code. If there is a second location procedure (such as a HCPCS code for right or left), use the CPT® modifier first.
Modifier 50 Bilateral procedure describes procedures or services that take place on identical, opposing structures (e.g., shoulder joints, breasts, eyes). Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services) during the same session.
Another example would be if the patient were having a nerve conduction study with CPT codes 95900 and 95903 being billed. If the two procedures are done on separate nerves, then the 59 modifier should be used to indicate that. If the codes were performed on the same nerve, then the 59 modifier should not be used.
CPT modifier 57 may be used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursem*nt process first.
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.
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).
CPT guidance throughout the laboratory code section often advises that modifier 59 should be used for “different species or strains reported by the same code” or for “multiple specimens or sites”.
There are instances where multiple procedures are performed but modifier 51 is not appropriate. Modifier 51 is not appended to add-on codes. For example, modifier 51 would not be appended to CPT code 64462 as it is an add-on code and would be used for any additional injection sites per its definition.
Modifier -22: Increased Procedural Services. This modifier is used to identify a service that requires significantly greater effort, such as increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required, than is usually needed for that procedure.
Modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure during the post-operative period.
Always add 26 before any other modifier. If you have two payment modifiers, a common one is 51 and 59, enter 59 in the first position. If 51 and 78, enter 78 in the first position.
Per the AMA, modifier 51 may be appended to medical procedures when medical and surgical procedures are performed in combination during the same session or when multiple medical procedures are performed in the same session.
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
To bill appropriately, you must add modifiers 59 (distinct procedural service) and 51 (multiple procedures). Modifier 59 informs the insurer that the two treatments performed are for different services, while modifier 51 alerts them that you are performing two or more separate treatments on the same day.
Introduction: My name is Merrill Bechtelar CPA, I am a clean, agreeable, glorious, magnificent, witty, enchanting, comfortable person who loves writing and wants to share my knowledge and understanding with you.
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