The Office of the Inspector General (OIG) released a report on the Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative (NCCI) Edits. Studies of randomly selected claims in 2003 show 40% misuse of modifier 59. The report showed that in 15 percent of modifier 59 cases, the services coded were not distinct. And in 25 percent, the services were not adequately documented. The audit also found that 11 percent of code pairs billed with modifier 59 in fiscal year 2003 were paid when modifier 59 was billed with the incorrect code. The OIG “recommended” that Centers for Medicare & Medicaid Services (CMS) pay closer attention to reporting and reimbursement errors.

Modifier –59 Distinct Procedural Service is described by the American Medical Association’s CPT 2006 Professional Edition as, “Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, 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 physician. 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”

Modifier –59 is an important NCCI modifier used to identify procedure/services that are not normally reported/billed together, but are appropriate under the circumstances and performed on the same date of service that represent a:

• different session or patient encounter
• different procedure or surgery
• different site or organ system
• separate incision/excision or lesion
• separate injury (or area of surgery in extensive injuries)

Physicians should only use –59 modifier when there is no other modifier more appropriate. You may only append modifier –59 to the lesser service(s). Remember Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.

Appropriate uses of modifier -59 could be with the nuclear medicine PET and PET/CT CPT 78814-78816 codes with a separately ordered, medically necessary diagnostic CT performed during a different session and reported on the same day with the PET or PET/CT scan. Another example is Column 1 code/Column 2 93015/93040, CPT code 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report and CPT code 93040 Rhythm ECG, one to three leads; with interpretation and report the policy here is that typically an ECG is part of CPT 93015 as the more extensive procedure. However, it may be appropriate to use modifier-59 if the rhythm ECG service is perform unrelated to the cardiovascular stress test procedure at a different patient encounter.

More information about the national correct coding initiative can be found at http://www.cms.hhs.gov/NationalCorCodInitEdits/