Modifier 59 Clarification

June 14, 2011

It seems the traditional understanding of modifier 59 has changed. Here's information for your medical practice.

Question: Has there been a change in the definition of modifier 59?

Answer: There is some evidence that Medicare and the AMA have changed the way they view modifier 59. This may fall short of a documented change in the way claims are currently adjudicated relative to 59, but comments have been made by sources close to the AMA that seem to change the traditional understanding of this modifier.

There has been no change in the definition of either modifier 51 or 59 in the 2011 CPT manual, but maybe there needs to be. The definition for modifier 59 states that it may be used for "procedures or services not normally reported together" and states that the documentation must support a "…different procedure or surgery, different site or organ system, separate incision/excision, separate lesion," etc. For most of us, and for many years, this was taken quite literally, such that separate lesions excised would be reported with the primary code alone, followed by the additional lesion removal coded with a 59. The same would hold true for different surgeries in different sites.

If I were to code for excision of a 2 cm malignant lesion from the arm, for example, and then the excision of a 2 cm malignant lesion from the neck, I would use the excision codes representing the removals from each of those anatomic sites and put a 59 on the second one. That is what CPT says to do.

Now we are hearing that modifier 59 was only ever intended for use on codes that are bundled by NCCI edits - and that if there is no edit, you shouldn't use modifier 59. Medicare is well within its rights to make such a policy if it so desires, and the AMA could support it if it chose to. But if this is the case, then the CPT manual should make this clear. And it's unlikely that such a decision would go unchallenged by specialty associations. In the lesion excision example I gave above, there are no column one and two edits on the excision codes - so this more recent discussion suggests that I would only be paid 50 percent for the second lesion.

We'll keep you posted on this topic.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the February 2011 issue of Physicians Practice.