CORRECT USAGE OF MODIFIER 59

This article replaces and rescinds any previous communication from Cahaba regarding the usage of Modifier 59 and Modifier 76. Please begin following these guidelines immediately.

***Note: If providers need to take any action to correct the claim denials associated with Modifier 59 that occurred during October through December 2009, Cahaba will issue specific instructions to the providers. No action is required by the providers at this time.

MODIFIER 59 is defined as a DISTINCT PROCEDURAL SERVICE: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 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. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25.

Modifier 59 is to be used as the modifier of last resort and “only if a no more descriptive modifier is available”. Modifier 59 cannot be used to unbundle a CCI code pair that has a modifier indicator of ‘0’.

Modifiers to consider before using Modifier 59 include:

50---Bilateral procedure: Use this modifier to indicate that the same procedure is performed at the same operative session on bilateral anatomical body parts (ex: knees, ankles, eyes, ears, etc). Note: This modifier should not be used with skin lesion removal. Unless otherwise indicated in the CPT listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate 5 digit code.

76---Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service. This is a repeat of the same procedure, on the same exact body site, on the same patient, by the same physician.

LT---Left side: Used to identify procedures performed on the left side of the body.
RT---Right side: Used to identify procedures performed on the right side of the body.
E1---Upper left, eyelid
E2---Lower left, eyelid
E3---Upper right, eyelid
E4---Lower right, eyelid

FA---Left hand, thumb
F1---Left hand, second digit
F2---Left hand, third digit
F3---Left hand, fourth digit
F4---Left hand, fifth digit
F5---Right hand, thumb
F6---Right hand, second digit
F7---Right hand, third digit
F8---Right hand, fourth digit
F9---Right hand, fifth digit

TA---Left foot, great toe
T1---Left foot, second digit
T2---Left foot, third digit
T3---Left foot, fourth digit
T4---Left foot, fifth digit
T5---Right foot, great toe
T6---Right foot, second digit
T7---Right foot, third digit
T8---Right foot, fourth digit
T9---Right foot, fifth digit

After you have considered all of the above modifiers and there is not another more specific and descriptive modifier to explain that the procedure or service was a distinct or independent procedure or service on the same day, then ensure that your documentation supports the distinct procedure or service, and submit the procedure code with modifier 59.

Page last updated: February 12, 2010

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