Appropriate use of modifier 59
Modifier 59: In a nutshell
- Modifier 59 is used when you perform two or more distinct procedures in one visit.
- It is one of the most misused modifiers and can result in not getting paid for your services.
- You should only use modifier 59 if no other modifier more accurately describes the circumstance or procedure or service.
Modifier 59 ensures appropriate payment for distinct, independent procedures performed by a single provider, in one day. Before you apply modifier 59, it’s important to answer the following question: Is using modifier 59 even appropriate? Its use is not based off the value of a CPT code but rather the PTP national edits information found on CMS’s website. For more information, visit Modifiers and the NCCI edits.
If you constantly provide multiple procedures in one visit, don’t panic — you can still get paid for all of your services. You just need to become familiar with modifier 59. Some appropriate use scenarios for modifier 59 are listed in the table below.
| Action | Example | Solution | Comment |
|---|---|---|---|
When you perform two different procedures during the same appointment. |
A patient who gets a mole removed on her left arm and also gets treatment for facial acne. |
Modifier 59 is appropriate when performing two clearly independent procedures. |
Generally, this means working on two separate anatomical sites. However, don’t add on modifier 59 if you’re treating contiguous structures on the same organ or anatomic region, as these are not considered different anatomic sites. |
When having two encounters with the same patient on the same day. |
You see the patient once in the morning and again in the afternoon for 2 different procedures. |
Use modifier 59 to make sure that you get paid for both encounters. |
They cannot both be for the same diagnosis —they must be clearly documented that the procedure was performed on separate anatomic sites. However, if the second procedure is on another day within the global period of the first one, you may need to use a different modifier. |
When procedures are mutually exclusive |
You perform an excision and a biopsy on two separate lesions during the encounter on the same day and patient. |
Mutually exclusive procedures are ones that generally cannot reasonably be performed at the same anatomic site or same patient encounter. |
Modifier 59 allows you to explain, “Well, this time, it was reasonable.” |
X[ESPU] Modifiers
In 2015, CMS realized that providers commonly misuse modifier 59 because they have difficulty specifying a distinct service. Their response? The modifier got modified. They issued X-ESPU — a subset of more specific modifiers that, when appropriate, can be used in place of modifier 59.
Many Medicare carriers know that the X-ESPU modifiers don’t always accurately reflect a dermatology appointment, so they continue to accept modifier 59 over the subsets. Check with your local carrier about their preference.
If you can’t use X-ESPU modifiers, you can still get more specific than modifier 59. The HCPCS code set includes modifiers that specify laterality (right and left), exact eyelids, and individual fingers/toes. CMS would much prefer you to use these modifiers instead of 59, as they more exactly describe the locations of the lesions in the two separate CPT codes.
You can test your knowledge of modifier coding by taking a short Academy quiz, or see other coding quizzes.
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