Using modifier 59, distinct procedure/service
Modifier 59 is used to identify procedures/services that are commonly bundled together but are appropriate to report separately under some circumstances. A health care provider may need to use modifier 59 to indicate that a procedure or service was distinct or independent from other services performed on the same day. This commonly means a different location, different anatomical site, and/or a different session.
For guidance on proper use of modifier 59, see your CPT Manual or the CMS Modifier 59 download.
- Providers must maintain adequate documentation in the medical record to support the use of modifier 59 for distinct services.
- For CPT codes reported with modifier 59 on or after Jan. 1, 2015, Priority Health requires that you submit medical records with the initial claim.
- Although modifier 59 may be appended to a claim line on first submission, this does not guarantee reimbursement of these services. Documentation must support a distinct procedural service.
- Addenda or amendments to the documentation will not be accepted after a claim has been denied.
- If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier 59 for that claim line, we will require medical records in order to process the corrected claim.
- Using modifier 59 to indicate different procedures or surgeries does not require a different diagnosis for each HCPCS/CPT-coded procedure/surgery.
- Different diagnoses are not adequate criteria for use of modifier 59.
Using modifier 59 with physical therapy codes
When appending modifier 59 to physical therapy codes, your documentation must support that distinct services were rendered. Effective Jan. 1, 2015, the more specific XE or XP modifiers may be used to distinguish a different session or practictioner performing the services. Learn more about the XE and XP modifiers.
Appending modifier 59 should be the exception, not the rule. Overusing this modifier may trigger a review of your medical records or an audit of your claims.
Appending the appropriate GO or GP modifiers to therapy services helps distinguish whether or not services should be bundled. Modifiers 59, XE or XP would not replace the need for the GO or GP modifier. Learn more about using the GN, GO and GP modifiers.
Inappropriate use of modifier 59
Inaccurate or inappropriate use of this modifier can generate overpayments, incorrect coding, and increased member cost sharing. In many cases, there is a more suitable modifier that may expedite claims processing. Modifier 59 should only be used if no other modifier more appropriately describes the relationship(s) of the two or more procedure codes.
For example, when commonly bundled procedures are performed on different fingers or toes, the use of finger (F1, F2, F3, etc.) or toe (T1, T2, T3, etc.) modifiers would be more appropriate than the 59 modifier to show that these are distinct services and create a clearer picture for the claim examiner as to why the services were unbundled. This may reduce the need for operative notes or medical office notes.
Other examples when modifier 59 is not appropriate:
- With unlisted codes
- With some HCPSC or CPT codes, such as J codes or L codes
- To describe separate encounters, structures, practitioners or unusual non-overlapping services. See Modifiers XE, XS, XP and XU.