CMS Updates MLN Matters Article on Proper Modifier -59 Use

CMS has recently updated an MLN Matters article to clarify the proper use of modifier -59.

There are two revisions made to MLN Matters article number SE1418 (pdf). One revision corrects a code in one of the examples provided to help guide use of modifier -59 while the other revision is an editorial change in different example.

The CPT Manual defines modifier -59 as follows:

"Distinct Procedural Service: 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/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 procedure or surgery, different site or organ system, separate incision/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 already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25."

Modifier -59 is an important and commonly used modifier, and one that is frequently used incorrectly. In fact, an OIG report (pdf) published in 2005 found that 40% of code pairs billed with modifier -59 in FY 2003 did not meet program requirements, resulting in $59 million in improper payments.

If you use modifier -59 in your organization, take this opportunity to not only review the revised MLN Matters article to see if the revisions apply to you but also to refresh yourself on the rules its proper use. This will help ensure you get paid appropriately for services provided that require you to use (and not use) modifier -59.


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