Monday, June 14, 2010

Distinct procedural service - Modifier 59

Part - A  Level I Modifiers 59

Description Distinct procedural service.
Required for Claims Hospital Outpatient Prospective Payment System (OPPS), Free-Standing Physical Therapy/Speech-language Pathology, Skilled Nursing Facility, End Stage Renal Disease (ESRD) Facilities

Type of Bill: 12X, 13X, 14X, 22X, 23X, 72X, 74X

Coding Guidelines Generally applied to surgical (CPT 10000-69990), radiological procedures (CPT 70010-79999) and other diagnostic services (CPT 90281-99569). May also be used for physical therapy, occupational therapy, Speechlanguage pathology services and non-diagnostic clinical laboratory services.

General Guidelines

A. In certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other services that were performed on the same day. The –59 modifier is used to identify
procedures/services that are not normally reported together but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ
system, separate incision/excision, separate lesion or separate injury.

B. Modifier –59 is appropriate to report multiple service submissions by a clinical laboratory for the same beneficiary on the same day. These situations usually involve microbiology where samples or cultures are taken from a patient from different anatomical sites or different wounds (same CPT code). These cultures are then tested on the same day.

C. Therapy services that are performed on two separate areas of the body (e.g. upper extremity and lower extremity) modifier –59 can be used to denote separate anatomic sites.

D. When it is appropriate to use a modifier, the most specific modifier should be used first. Up to two (2) sets of modifiers can be used per line item. Level I modifiers should generally be used before Level II HCPCS
modifiers. However, when modifiers E1 through E4, FA through F0, LC, LD, RC and TA-T9 apply, they should be used before modifiers LT, RT, or –59.

E. Modifier –59 and modifier –91 should NOT be used interchangeably.

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