Provider Alerts

Health Plan has identified through internal claims auditing the overutilization or improper use of MODIFIER 59 along with no supporting documentation to support the use of the modifier.

Modifier 59 is an important National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) associated modifier that physicians and providers often use incorrectly.

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Evaluation/Management (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.

Appropriate and Inappropriate Use of Modifier 59

1. Using modifier 59 properly for different anatomic sites during the same encounter only when procedures which aren’t ordinarily performed or encountered on the same day are performed on:
   1. Different organs
   2. Different anatomic regions
   3. In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ
2. Only use modifier 59 if no other modifier more properly describes the relationship of the 2 procedure codes by the more specific NCCI-PTP associated modifiers.
3. Don’t use modifier 59 just because the code descriptions of the 2 codes are different.
4. Other specific proper uses of modifier 59
   1. Two services described by timed codes provided during the same encounter only when they’re performed one after another
   2. Diagnostic procedure which is performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
   3. Diagnostic procedure which occurs after a completed therapeutic procedure only when the diagnostic procedure isn’t a common, expected, or necessary follow-up to the therapeutic procedure.

The use of modifier 59 doesn’t require a different diagnosis for each HCPCS or CPT code procedure.  On the other hand, different diagnoses aren’t adequate criteria for the use of modifier 59. The HCPCS or CPT codes remain bundled unless you perform the procedures at different anatomic sites or separate patient encounters or meet 1 of the other 3 scenarios described by a, b, c above.

Refer to National Correct Coding Initiative website at https://mcweb.apps.prd.cammis.medi-cal.ca.gov/references/ncci for general information about the NCCI program, NCCI PTP edits, Correct Coding Modifier Indicators (CCMIs), and PTP-associated modifiers. Additional information, including How to Use NCCI Tools booklet can be found at https://www.cms.gov/medicare/coding-billing/ncci-medicare.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org