As a Medical Coder, How Do You Manager the Dreaded Modifier 59?

by  Find-A-Code™
Nov 2nd, 2023

Medical billing codes are challenging enough even when things are straightforward. But throw in a modifier and you have the potential for all sorts of trouble. Take Modifier 59. It is among the most dreaded modifiers that medical coders and billers need to handle. Get it wrong and you could wind up with a denied claim or, worse yet, accusations of unbundling.

Modifiers in medical coding are used to denote circumstances that do not line up with a normal way of doing things. Modifier 59 denotes multiple services provided on the same day, often during the same visit, despite being distinct and different. Billing them as separate services usually means a higher bill total. Therefore, payers scrutinize the use of the modifier.

When the Modifier Is Called For

Modifier 59 is designed to be used when multiple procedures or services are rendered. There are numerous scenarios under which this could happen. As a general rule, there are four questions that go into deciding whether to use it:

• Were the procedures performed on different anatomic sites?
• Were the procedures performed during different patient sessions?
• Were the procedures performed using different techniques or equipment?
• Were the procedures performed with different goals in mind?

Once again, the purpose of Modifier 59 is to bill separately for services and procedures that are distinct despite being provided on the same day and/or during the same session. Perhaps a few examples would make this easier to understand.

1. Patient Biopsies

It is not unusual for doctors to order multiple biopsies on a single patient. During a single visit, a sample might be taken from the patient's arm, followed by a second sample taken from a leg. The two biopsies could be billed separately using Modifier 59.

2. Physical Therapy

In a physical therapy session, it is not unusual for therapists to provide both manual therapy and opportunities for the patient to engage in scheduled exercise. Manual therapy on a shoulder could be billed separately from exercises designed to strengthen the patient's back even though both occurred during the same session.

Of course, neither of these examples is black-and-white. Most of what goes into applying Modifier 59 depends on the circumstances of the session in question. Coders must try to understand clinician rationale and intent in order to determine which codes to utilize, including codes with modifiers.

It should be noted that Modifier 59 is considered a last-resort modifier. It should only be used when there are no other modifiers that more accurately explain what happened during the session being billed for.

Modifier 59 and Payer Audits

This particular modifier is one that medical coders and billers are especially uncomfortable with. Why? Because it happens to be a favorite among payers who decide to audit billers. Modifier 59 is closely tied to the bundling and unbundling practices. When used improperly, it could lead to higher bills that payers are not especially fond of paying.

Experts recommend using Modifier 59 with caution. If it can be avoided without negatively impacting a healthcare provider's ability to be fully reimbursed, it is probably better to do so. Coders and billers who find themselves in a position of not being able to decide whether to use the modifier should not be afraid to ask for advice from peers.

Modifiers are a normal part of medical coding and billing. Some are easier to apply than others. Unfortunately, Modifier 59 is among the harder modifiers to use. But it is not going away. Coders and billers just need to make the best of it.