Greetings, WebPTers! First, let me say thank you for the opportunity to chat with you today about appropriate use of the 59 modifier in 2014. 

Even though we’ve been using the 59 modifier for some time now, there is still plenty of confusion and misunderstanding about when and how to use it. In fact, when we created our compliance plan, we listed use of the 59 modifier as a risk to be assessed and monitored.

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When to Use the 59 Modifier

The CPT Manual describes the 59 modifier as a means to indicate a “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 and management (Evaluation and Management) services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together, but can be reported together under the circumstances.
  • Documentation must support a different session, different procedure, or a different site of treatment not ordinarily encountered on the same day or rendered by the same individual. 
  • Use the 59 modifier only if no more descriptive modifier is available and the 59 modifier best explains the circumstances. 

Going by the above description, we would apply the 59 modifier when we have performed:

  • a “separate and distinct” procedure or
  • a procedure on a “separate and distinct” body part.

However, we would only apply modifier 59 in the above scenarios if:

  • there were no other modifier that supplied a better description of the service, and
  • our documentation supported the use of the modifier.

I would like to emphasize the importance of the last part of that statement. We never want to apply a modifier—or anything else—to a claim simply because we may have heard somewhere that we’ll get paid if we do. Our documentation always has to support what we bill to any insurance provider.

One of the most common uses of the 59 modifier occurs when two timed code procedures are performed sequentially in the same encounter. For example, let’s say CPT codes 97140 (Manual Therapy) and 97530 (Therapeutic Activities) are performed in separate 15-minute intervals on the same date of service. If the therapist’s documentation supports the fact that the time-based procedures were performed “separate and distinct” of each other, then it would be appropriate to add the 59 modifier to the claim submitted for that date of service.

In the documentation, the therapist could add something like, “Manual Therapy and Therapeutic Activities were performed on this date of service as separate and distinct procedures.”

Another appropriate use of the 59 modifier: a therapist precedes a therapeutic procedure with a diagnostic procedure, because the diagnostic procedure is the basis for performing the therapeutic procedure.

For example, let’s say a current patient presents with a new diagnosis not currently being treated. In this situation, it would be appropriate to perform a re-evaluation (97002/97004) before beginning treatment for the new diagnosis. The keys to this example are:

  • The re-evaluation and the therapeutic procedure are separate and distinct.
  • The re-evaluation is completed prior to beginning treatment (treatment can begin on the same date of service).
  • Documentation must support that the therapist met the criteria for a re-evaluation.
  • The findings of the re-evaluation lead to the appropriate therapeutic procedure.
  • If the diagnostic procedure is an inherent part of the treatment procedure, they should not be billed separately.

I would like to provide a word of caution here: the 59 modifier should not be used consistently with a re-evaluation procedure code for routinely reporting progress.

In the documentation, the therapist could add something like, “Patient presents this day with a new diagnosis for [Name of Diagnosis].  A Re-evaluation was performed; see full RE for details.  As a direct result of the new impairments identified in the RE, treatment was provided to [Area of Treatment].”

I would like to thank you again for the opportunity to present to you on appropriate use of the 59 modifier, and I’m looking forward to co-presenting with Heidi during the Modifier Open Forum on June 27. For details on CCI edits and edit pairs, check out this blog post. If you have questions on the information presented here, post them in the comments below.

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