Modifier used in ASC – 59

by | Jun 7, 2010 | CPT modifiers

Some of the most common modifiers used in the ASC are: 

Modifier 59: Distinct Procedural Service Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician. Although the modifier has several different reporting uses, it should only be used if another more descriptive modifier is not available and its use best describes the circumstances.

Caution should be used with modifier 59, as this is one of the most misused modifiers. If this modifier is not used appropriately, the claim will be denied. The denial from the carrier states, “Medicare does not pay for this service because it is part of another service that was performed on the same day.”

For example: A patient presents with a 4.5 malignant lesion on the arm. He also has a sore on his leg. The physician excises the lesion on the arm and does a biopsy on the leg.
CPT codes:
11606 excised lesion over 4 cm on leg
11000-59 biopsy of skin

As coding guidelines state, if a biopsy is performed with an excision on the same site, then you would code the excision only. But in the above example, the excision and biopsy were performed on different sites. Modifier 59 lets the payer know that this service should not be bundled into the excision code because it was performed on a distinctly different site. Normally, a biopsy is considered inherent to an excision procedure.

The best way to know if modifier 59 is the correct modifier is to see if the CMS National Correct Coding Initiative (NCCI) contains an edit that prohibits the two procedure codes from being billed together. If NCCI unbundles the codes, but your services were provided on distinctly different sites, then modifier 59 is appropriate. In the event that a more descriptive modifier is available, it should be used in preference to modifier 59.