Meaning of modifier 59 and how is it used when billing Medicare

Per the CPT manual, the descriptor of modifier 59 is:

• "Distinct procedural service"

As indicated, under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management services performed on the same day.

Modifier 59 is used to identify procedures / services, other than evaluation and management (E/M) services, which are not normally reported together, but are appropriate under the circumstances. Documentation must support:

• Different session
• Different procedure or surgery
• Different body site or organ system
• Separate incision or excision
• Separate lesion
• Separate injury (or area of injury in extensive injuries)
• When the procedure is not ordinarily encountered or performed on the same day by the same individual
• When no other established modifier is more descriptive / appropriate

Note: Only if no more descriptive modifier is available (and the use of modifier 59 best explains the circumstances) should modifier 59 be used. To determine if a more appropriate modifier exists within the subset of modifier 59, be sure to review the MLN fact sheet - Proper use of Modifiers 59 and X(EPSU) on specific modifiers for distinct procedural services.

Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service on the same day, modifier 25 may be more appropriate.

Be sure to view the decision flowchart for additional assistance on determining when to use modifier 59.

For additional information on modifier 59, access the MLN fact sheet - Proper use of modifiers 59 and X(EPSU) on the proper use of modifier 59.

References

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30(M)
• American Medical Association's (AMA) CPT Manual, Appendix A
• MLN fact sheet - Proper use of modifiers 59 and X(EPSU)