Article - Billing and Coding: CPT® Modifier 59: Gastroenterology (A53399)

CMS National Coverage PolicyN/AArticle TextBackgroundUnder certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services and CPTmodifier 59 may be appropriate depending on the circumstances. CPTmodifier 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 differentSession or patient encounterProcedure or surgerySite or organ systemA separateIncision/excisionLesionInjury (or area of injury in extensive injuries)When another already established modifier is appropriate, it should be used rather than CPTmodifier 59. CPTmodifier 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 CPTmodifier 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/CPTcodes 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 sitesDifferent patient encountersThe Part B MAC claim processing system utilizes NCCI-associated modifiers to allow payment of both codes of an edit.CPTmodifier 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 CPTmodifier 59 is related to the portion of the definition of CPTmodifier 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 CPTmodifier 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, CPTmodifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.Use of CPTmodifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPTcoded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of CPTmodifier 59. The HCPCS/CPTcodes 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 CPTModifier 59 UsageThe following are some examples developed to help guide physicians and providers on the proper use of CPTmodifier 59:Example 1:Column 1 Code/Column 2 CPTCode 45385/45380CPTcode 45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare techniqueCPTcode 45380 - Colonoscopy, flexible; with biopsy, single or multiplePolicy: More extensive procedureCPTmodifier 59 is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.