Billing and Coding: CPT Modifier 59: Gastroenterology

**Background**  
  
Under certain circumstances, a physician may need to indicate that a procedure
or service was distinct or independent from other services and CPT modifier
59 may be appropriate depending on the circumstances. CPT modifier 59 is used
to identify procedures/services that are not normally reported together and
this includes the following procedures/services that are not ordinarily
encountered or performed on the same day by the same physician:  
  

    * A different

                 Session or patient encounter

                 Procedure or surgery

                 Site or organ system



    * A separate

                Incision/excision

                Lesion

                Injury (or area of injury in extensive injuries)

  
When another already established modifier is appropriate, it should be used
rather than CPT modifier 59. CPT modifier 59 is an important National
Correct Coding Initiative (NCCI) associated modifier that is often used
incorrectly and it should only be used if no more descriptive modifier is
available or when its use best explains the circumstances.  
  
For the NCCI, the primary purpose of CPT modifier 59 is to indicate that two
or more procedures are performed at different anatomic sites or during
different patient encounters. It should only be used if no other modifier more
appropriately describes the relationships of the two or more procedure codes.  
  
NCCI edits define when two procedure HCPCS/CPT codes may not be reported
together except under special circumstances.  
  
If an edit allows use of NCCI-associated modifiers, the two procedure codes
may be reported together if the two procedures are performed at:

    * Different anatomic sites

    * Different patient encounters

  
The Part B MAC claim processing system utilizes NCCI-associated modifiers to
allow payment of both codes of an edit.  
  
CPT modifier 59 and other NCCI-associated modifiers should not be used to
bypass an NCCI edit unless the proper criteria for use of the modifier is met.
Documentation in the medical record must satisfy the criteria required by any
NCCI-associated modifier used.  
  
One of the misuses of CPT modifier 59 is related to the portion of the
definition of CPT modifier 59 allowing its use to describe 'different
procedure or surgery.' The code descriptors of the two codes of a code pair
edit usually represent different procedures or surgeries. The related NCCI
edit indicates that the two procedures/surgeries cannot be reported together
if performed at the same anatomic site and same patient encounter. The
provider cannot use CPT modifier 59 for such an edit based on the two codes
being different procedures/surgeries. However, if the two procedures/surgeries
are performed at separate anatomic sites or at separate patient encounters on
the same date of service, CPT modifier 59 may be appended to indicate that
they are different procedures/surgeries on that date of service.  
  
Use of CPT modifier 59 to indicate different procedures/surgeries does not
require a different diagnosis for each HCPCS/CPT coded procedure/surgery.
Additionally, different diagnoses are not adequate criteria for use of CPT
modifier 59. The HCPCS/CPT codes remain bundled unless the
procedures/surgeries are performed at different anatomic sites or separate
patient encounters.  
  
From an NCCI perspective, the definition of different anatomic sites includes
different organs or different lesions in the same organ. However, it does not
include treatment of contiguous structures of the same organ. For example,
treatment of the nail, nail bed and adjacent soft tissue constitutes a single
anatomic site. Treatment of posterior segment structures in the eye
constitutes a single anatomic site.  
  
**Examples of CPT  Modifier 59 Usage**  
  
The following are some examples developed to help guide physicians and
providers on the proper use of CPT modifier 59:  
  
**Example 1:** Column 1 Code/Column 2 CPT Code 45385/45380  
  

    * CPT code 45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

    * CPT code 45380 - Colonoscopy, flexible; with biopsy, single or multiple

  
  
**Policy: More extensive procedure**  
  
CPT modifier 59 is only appropriate if the two procedures are performed on
separate lesions or at separate patient encounters.