Thursday, August 26, 2010

Distinct Procedural Service - Medicare modifier 59

Modifier 59 Fact Sheet

Definition:

• Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.

Appropriate Usage:

• Documentation indicates two separate procedures performed on the same day by the same physician
             o Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)

• Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in Correct Coding Initiative (CCI) edits.

• Use Modifier 59 when there is NO other appropriate modifier.

Inappropriate Usage:

• Code combination not appearing in the CCI edits
• Submission of E/M Codes
• Submission of Weekly radiation therapy management codes (CPT 77427)
• MPFSDB lists the procedure code listed with a modifier indicator of “0”
• Documentation does not support the separate and distinct status
• Exact same procedure code performed twice on the same day
• If a valid modifier exists to identify the services


Additional Information:

• CCI listings can be found at the following Website address:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/

• Medicare considers two physicians in the same group with the same specialty performing services on the same day the same physician.

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