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.
- Providers must maintain adequate documentation in the medical record to support the use of modifier 59 for distinct services.
- 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 (different session/patient encounter or different procedure/service) were rendered. Appending this modifier 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.
Inappropriate use of modifier 59
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