Modifier 59 unbundles services billed together on the same day. CMS defines Modifier 59 as:
“Modifier 59 identifies appropriate procedures not typically reported together.”
Coding pairs, or edits, can create mutually exclusive services. Coding pairs allow one service to be paid, with exceptions for separate performances. Without Modifier 59, unjustified coding pairs may not be reimbursed as distinct services. That’s where Modifier 59 and its subsets come to the rescue!
Modifier 59 is the most abused modifier, per OIG audits. We aim to review proper Modifier 59 use to improve claim accuracy impacted by bundling edits.
At times, when unsure, coders can look up NCCI edit files presented by CMS. NCCI PTP edits define appropriate code combinations.
NCCI indicators specify if Modifier 59 use is allowed (1) or not (0) for code pairs.
Modifier 59 bypasses CCI edits under specific circumstances.
Modifier 59 should only be used in genuine circumstances. To curb the misuse of Modifier 59, in 2015, CMS introduced the use of Subsets of Modifier 59 (X{EPSU}). Use subsets to specify Modifier 59 circumstances. CMS introduced new modifiers to override edits.
OIG reports highlight a lack of documentation in Modifier 59 abuse/fraud cases. Cases linked to insufficient documentation where services were not clearly distinguished.
Modifier 59 abuse cases caution organizations about improper use. Frequent modifier 59 use risks OIG or external audits.
Appending Modifier 59 recklessly can lead to audit risks. Use Modifier 59 subsets when possible to better explain its use.
Ensure documentation of medical necessity for each procedure and alignment of modifier use with guidelines.
Proper Modifier 59 use requires internal audits and documentation. Proper Modifier 59 use ensures fair payment and defends against audits.
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