A modifier should never be applied to increase reimbursement or to receive payment for an operation that would otherwise be packaged with another code. Modifier 59 identifies a distinct procedural service and is used to distinguish solutions and processes that are not generally recorded in the same report. It should be used, when coding for a particular session, a different treatment or surgery, another site or organ system, a separate incision/excision, a separate lesion (non-contiguous lesions in different anatomic parts of the same organ), or separate damage. Modifier 59 should only be used on Evaluation and Management Codes when no other modifier is applicable.
Distinct Procedural Service:
It may be essential to state that a procedure or service was different or independent from other non-E/M services done on the same day under specific circumstances. Other than E/M services, modifier 59 highlights approaches that are not generally reported concurrently but suitable for the conditions.
When Should You Use the 59 Modifier?
The 59 modifier is among the most commonly misapplied modifiers. The most typical reason for using it is to show that two or more treatments were conducted at the same visit but distinct locations on the body.
Unfortunately, it is frequently used to prevent a service from being bundled or included in another claim. It should never be used to prevent services from being packaged or bypass the insurance carrier’s edit system. If another modifier better represents the services being billed, it should be used instead of the 59 modifiers.
When utilizing the 59 modifiers to signify a different and independent service, documentation proving that the services were conducted independently should be kept in the patient’s medical file. Before refunding the entire amount for the changed CPT code, the insurance company may request that the record be reviewed to determine whether the 59 modifiers are adequately used.
The use of the 59 modifier does not necessitate the use of a new or separate diagnosis code for each of the treatments billed. As a result, providing different diagnosis codes for each service done does not justify using the 59 modifiers.
How to Avoid Modifier 59 Denials?
Payers depend on the information supplied to them to be correct and assume there is evidence backing it up because claims are handled without the physician’s paperwork. Unfortunately, modifier 59 is frequently misapplied. As a result, some payers now immediately dismiss CPT codes that include modifier 59. That compels the provider to file an appeal and submit proof that modification 59 was correctly applied.
This rejection and appeal procedure is costly for both the provider and the payer. It delays payment and requires the provider’s staff to draught appeals while also requiring the payer’s personnel to study paperwork and process appeals.
The 59 Modifier’s Use and Reimbursement
Modifier 59 is used adequately for different anatomic locations during the same encounter only when processes that are not customarily conducted or encountered on the same day are performed on other organs, anatomic regions, or, in narrow circumstances, on different, non-contiguous lesions in various anatomic areas of the same organ.
When the operations are conducted in different meetings on the same day, the 59 modification is suitable. The modifier is misused if its use is because the narrative descriptions of the two codes disagree.
The 59 modifier is applicable only when two services described by timed codes are executed consecutively during the same interaction.
Modifier 59 is acceptable for a diagnostic process that comes before a therapeutic procedure only if the diagnostic approach serves as the foundation for completing the therapeutic operation.
The modifier is acceptable for a diagnostic process that occurs only after a finished therapeutic procedure if the diagnostic system is not a common, expected, or required follow-up to the therapeutic operation.
If you are the biller and consider that modifier 59 should have been included but was not, you should contact the provider to check if it was missing by mistake. Do not just add the modification to the claim unless there is solid proof that it is required. However, it is critical to check with your local carrier to see which modifiers they accept and under what conditions. Misusing 59 or any other modifier may result in a payer rejecting your claim entirely. Avoid claim problems by using them correctly at all times.
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