Proper Use of the 59 Modifier

•     •      Under certain circumstances, it may be necessary to indicate that a procedure or service was Distinct or Independent from other non- E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.
•     •      Documentation must support a Different session, Different surgery or procedure, Different site or organ system, Separate incision or excision, Separate lesion, or Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
•     •      However, when another established modifier is appropriate it should be used rather than modifier 59. Thus, the physician or his/her designated appointee, the biller or the coder need to perform a modifier search to determine whether there is another modifier that should be used in lieu of the 59 modifier. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. The bottom line is that modifier 59 is not the modifier of first choice, rather it is the modifier of last resort.
•     •      How does CMS know whether the 59 modifier is being used correctly? They have software that determines this fact. There is a “Four Bullet Punch List” that determines whether the 59 modifier was used correctly. Anytime the use of the 59 modifier is contemplated, one must apply the CPT code in question to each of the “Four Bullets.” If it passes four out of four, it is appropriate to append the 59 modifier to that CPT code.
•     •      THE “FOUR BULLET PUNCH LIST” FOR THE CORRECT USE OF THE 59 MODIFIER:
  •          ○     1. The 59 modifier is ONLY used on a procedure code, NEVER on an E/M code.
  •          ○     2. The procedure code in question is a DISTINCT or SEPARATE service from the other services performed on the SAME DAY.
  •          ○     3. The 59 modifier serves as an anatomical modifier. Why?

Because there is not available a true anatomical modifier to show the carrier that the procedure code in question is a separate service from the other services performed on the same day.

• •          ○     4. The 59 modifier is a multiple procedure modifier.

               There needs to be at least 2 procedures performed.

The 59 modifier is appended to the second procedure based upon how they are listed in the CCI edits.

Don’t “hedge your bets” by placing the 59 modifier on All of the CPT codes that you are billing that day. This is highly inappropriate.

MLN Fact Sheet Proper Use of Modifiers 59 & –X{EPSU}: MLN1783722 March 2022 – Example: Column 1 Code/Column 2 Code – 11055/11720

• • •                ‣     CPT codes 11720 and 11055 should not be reported together for services performed on skin distal to and including the skin overlying the distal interphalangeal joint of the same toe. Modifier 59 should not be used if a nail is debrided on the same toe on which a hyperkeratotic lesion of the skin on or distal to the distal interphalangeal joint is pared. Modifier 59 may be reported with code 11720 if one to five nails are debrided and a hyperkeratotic lesion is pared on a toe other than one with a debrided toenail or the hyperkeratotic lesion is proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided.

From The CMS Publication: “59 Modifier Article”

•     • ​​​​​​​     Modifiers XE, XS, XP, XU were effective January 1, 2015. These modifiers were developed to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more specific modifier is appropriate.) Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, providers were able to begin using them for claims with dates of service on or after January 1, 2015. The modifiers are defined as follows:
  •          ○     XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
  •          ○     XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
  •          ○     XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
  •          ○     XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

Please confirm with your Medicare Administrative Carrier, the Medicare Advantage Plans and the commercial health insurance carriers whether they require that you use the 59 modifier, the “X” Modifier Subset, or they leave the choice up to the provider.

This is my opinion.

Michael G. Warshaw

DPM, CPC​​​​​​​

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