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March 25, 2023

Using Modifier 59 | Quick Reference

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Modifier 59 is referred to by CMS as the modifier of last resort. It is often used when modifier 51 is the more accurate modifier. This quick reference sheet explains when, why and how to use it.

In addition, you will find tips related to:

  • A process to determine if modifier 59 can be used
  • Performed the same procedure twice in a single day
  • E/M and some HCPCS codes for Medicare
  • CMS developed HCPCS modifiers-X {EPSU} but never implemented them nationally (some MACs use them)

From CPT®:

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

Note: 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.

Other modifier resources

  • Using Modifier 25 | Quick Reference
  • Using Modifier 33 | Quick Reference
  • Modifiers in Primary Care
  • Other modifiers

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Relevant Search Terms: modifiers, modifier 59, NCCI, bundling, mutually exclusive edits, medically unlikely edits

Last revised March 15, 2023 - Betsy Nicoletti
Tags: general surgery_modifiers, modifiers, primary care_modifiers

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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