Sunday, January 16, 2011

cpt modifer 59 usage - distinct procedural service

Modifier 59 (Distinct Procedural Service)

Under certain circumstances, the physician may need to indicate that a
procedure or service was distinct or independent from other services
performed on the same day. Modifier 59 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 (or area of injury in extensive injuries) not ordinarily encountered or
performed on the same day by the same physician. 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.

According to the CPT book, modifier 59 is described as being necessary
to describe a distinct procedural service. This modifier should only be
used to show a distinct procedural service when a
comprehensive/component coding pair is billed. Modifier 59 should not
be billed to represent that multiple services of the same procedure code
were performed.

A comprehensive/coding pair occurs when one code is considered a
component procedure and the other code is considered a comprehensive
procedure. These code pairs are frequently referred to as bundled codes
thus meaning the component code is usually considered an integral part
of the comprehensive code. Therefore, in most instances the most
comprehensive code only should be billed and the component code
should be denied as rebundled or mutually exclusive.

Modifier 59 should only be used in conjunction with a
comprehensive/coding pair procedure when appropriately unbundling the
code pair. This modifier 59 should not be billed with the comprehensive
code. The component code can be unbundled, or allowed separately, in
certain situations. If the two services are performed at two different times of day or the services are performed in two different anatomical sites, then
modifier 59 can be submitted with the component procedure code.

In order to communicate the special circumstances of the
component/comprehensive code pair unbundling, diagnoses codes and
anatomical modifiers must be utilized as appropriate on the claim form. In
some cases, it may be necessary to attach a copy of the Operative Report
to further explain the reason for the unbundling of code pairs.

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