Modifiers 59 is the ‘go-to’ modifier that is used to ‘unbundle’ or appropriately distinct certain medical services that are billed together on same day. CMS defines Modifier 59 as:
“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.”
There are a number of medical services that can form a ‘Coding-pair’ or a ‘Coding-edit’ that the payer might consider mutually exclusive. Which means only one of the services in the pair if supposed to get paid, while the other one might not, but there are indeed medically appropriate circumstances where the services were needed to be performed separately. In those times, without Modifier 59, if these coding pairs are not justified as distinct to one another, the packaged service won’t get reimbursed. That’s where Modifier 59 and its subsets come to the rescue!
However, according to various OIG audit and review reports, Modifier 59 is found out to be most frequently abused Modifier there is. Taking this opportunity, we would like to explain in detail the appropriate and inappropriate use of Modifier 59 and how much we can improve the clarity and quality of billed claims that form these bundling edits.
At times when unsure, coders can look up to NCCI edits files presented by CMS. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure (PTP) edits that define when you should or should not use certain HCPCS or CPT codes together in specified situations.
For understanding when or when not to use the Modifier, we need to look for the indicators mentioned against a pair of codes in the NCCI edits file, for simplification “0” means NO and “1” means YES to the use of a Modifier.
Modifier 59 is one of the several modifiers, that are used to ‘by-pass’ these coding pair edits that are enlisted in CCI edits document presented by CMS.
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 these subsets instead, to let the payer in which circumstances Modifier 59 was intended. CMS introduced four new Modifiers that could help better explain the scenarios in order to over-ride the edits:
According to OIG reports on abuse/fraud settlements related to Modifier 59 use, they have made clear that there was a serious lack of documentation on the Practitioner’s part. Also, they have linked the cases to lack of evidence in the documentation where the services were not made distinct to each other, enough or at all.
Modifier 59 abuse settlement cases are found abundant online as a word of caution for many organizations getting under investigation quietly easily for its improper use. Frequent and unnecessary use of this modifier comes with perils of OIG or external audits.
Many billers are tempted to append Modifier 59 to a service to override an edit, but this can set up their medical practice for a substantial audit risk if it is applied recklessly. If Modifier 59 has to be appended, prefer opting for its subsets instead to better explain its actual reason for use.
In the end, a practice should make sure they document the medical necessity of performing each procedure, and include details beforehand showing how the use of the modifier is indicated by the guidelines.
Most proper use of Modifier 59 is through frequent internally scheduled audits (to catch the abuse in-advance) and documentation of appropriate use in medical notes. These might be the provider’s best defense against in case of an external audit which also may boost the chances of payment of a service fairly, when used correctly.
AltuMED is a Healthcare Revenue Cycle Management technology and solutions company. Our technologically advanced Practice Management Software, PracticeFit optimizes the Medical Billing workflows for Medical Practices, Labs and Third-Party Medical Billing Companies helping them collect maximum revenue. Find out more.
Subscribe to Our Newsletter!
Enter Your Email Address. We Promise We Won't Spam You
Informational
Educational
Medical Billing Software
Enter your email to receive our newsletter, so you can stay in the loop with our latest promos.
Subscribe to Our Newsletter!
Enter your email address to
receive "Go Practice" as an email newsletter.