Wednesday, June 26, 2019
Reimbursement Coding Articles

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When Not to Use Modifier 59

This article courtesy of American Academy of Professional Coders' (AAPC) John Verhovshek. AAPC is one of the nation's largest and most respected providers of education and professional certification to physician-based medical coders.

CPT® instruction is clear that modifier 59 doesn't apply to evaluation and management (E/M) codes. CPT® Appendix A, for instance, instructs, "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 performed on the same date, see  modifier 25." CMS and CCI guidelines stress the same points.

CPT® and CMS guidelines agree that modifier 59 should be the "modifier of last resort." As CPT® Appendix A explains, "Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

For example, a patient receives an excisional breast biopsy (19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions), which returns positive for malignancy. Several days later, the patient undergoes a modified radical mastectomy (19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

CCI bundles 19120 to 19307, but because documentation indicates the biopsy led to the decision to perform the mastectomy, the biopsy led to the decision to perform the mastectomy, the biopsy is separately payable. In this case, however, modifier 59 is inapporpriate. Rather, modifier 58, Staged or related procedure or service by the same physician during the postoperative period better describes the circumstances of the staged/more extensive procedure. Proper coding would be 19120, 19307-58.

A second example of when another modifier would apply before modifier 59 comes from the June 2002 CPT® Assistant:

For example, if three subsequent potassium level blood tests are ordered and performed on the same date as the initial test to obtain multiple results in the course of potassium replacement therapy, then report code 84132, Postassium; serum, plasma or whole blood once for each blood test performed, and append modifier 91, Repeat clincial diagnostic laboratory test to the subsequent test codes to identify the repeat clinical diagnostic laboratory tests performed.

Microbiology guidelines in the microbiology subsection of CPT® clarify the appropriate use of modifier 91, versus modifier 59, in this situation:

"Presumptive identification of microorganisms is defined as identification by colony morphology, growth on selective media, Gram stains, or up to three tests (eg, catalase, oxidase, indole, urease). Definitive identification of microorganisms is defined as an identification to the genus or species level that requires additional tests (eg, biochemical panels, slide cultures). If additional studies involve molecular probes, nucleic acid sequencing, chromatography, or immunologic techniques, these should be separately coded using 87140- 87158 , in addition to definitive identification codes. The molecular diagnostic codes (eg, 83890- 83914 ) are not to be used in combination with or instead of the procedures represented by 87140- 87158 . For multiple specimens/sites use modifier 59. For repeat laboratory tests performed on the same day, use modifier 91.


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