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When
Do I Use
Modifier
59?

Modifier -59 - For Distinct Procedural Service

Key Points to Remember:

  1. When using this modifier, Medical Documentation is vital and essential
    to support medical necessity. This must be well-documented on the
    patient's medical record.
  2. This modifier may represent a different body site or organ system.
  3. This modifier may represent a separate lesion.
  4. This modifier may represent a different area of injury.
  5. This modifier may represent a different procedure.
  6. This modifier may represent a separate incision or excision.
  7. This modifier represents a distinct and independent
    procedure/surgery/encounter from other services performed.


Sample Encounters:

Sample 1: General Surgery

The physician excised 2 lipoma on the patient's face area. Size is less than 2
cm.

Use CPT Code 21011 -
Excision, tumor, soft tissue of face or scalp,
subcutaneous; less than 2 cm

21011
21011-59 (for the second lesion)

Diagnosis: 214.0 - Lipoma of skin and subcutaneous tissue of face

>>>> make sure you point the correct diagnosis on each line.

Global Days: 90 days.

If you saw the patient within the global days for evaluation and management
unrelated to the procedure. See
Modifier 24.

Sample 2: Dermatology

A Dermatologist performs simple repair  of a superficial wound to the right
arm and also performs a debridement of another site but on the same arm
(for example, on the wrist -- and another on the upper arm).

>> Modifier -59 is very useful for coding and billing dermatology services.

Sample 3: Pain Management

The pain doc performs a facet nerve block L1-L2 and an SI Injection on the
same session:

64493 x 1 unit
27096 mod -59 x 1 unit <<=== is modifier 59 required here?; NO, as per
NCCI edits, these 2 codes has no conflicting relationship. You may or you
may not need that 59 modifier. But if you know it is not required, why will
you append the modifier 59?

Sample 4: Physical Therapy

A physical therapist treat a patient with different problem. One for his neck
and one for his back. During the same session, (CPT 97110) 15 minutes
each site (for back and neck).

Code first line 97110 without Mod- 59  
Code second line 97110 with Mod- 59


Read more on Modifier -59 Per CMS

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