Using Modifier 59, Distinct Procedural Service

Under certain 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.

• Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.
• Providers must maintain adequate documentation in the medical record to support the services billed.

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.

Physical Therapy
When appending modifier 59 to physical therapy codes, 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.

Inappropriate Use
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.