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.
Documentation requirements
- 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.
Diagnoses
- 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
