Correctly Using Modifier 59

Modifiers can be a helpful addition to medical billing. However, there are certain modifiers that are constantly used incorrectly. The contractors for the Centers for Medicare and Medicaid Services are now keeping an eye out for suspicious modifiers. The medical billing modifier 59 is on the list of modifiers to flag for review.

Recently, the U.S. Office of Inspector General released a report that showed some daunting medical billing news. Modifier 59 has been the cause of over $59 million in overpayments to nursing homes and providers. Due this large number of overpayments, Medicare contractors will be closely scrutinizing each medical billing submission that contains the modifier 59.

To prevent unnecessary medical billing audits, there are certain guidelines you should follow when deciding whether or not to use modifier 59. The first guideline is when you use modifier 59 for mutually exclusive Current Procedural Terminology code pairs. If there are two procedures performed, but completely separate from one another, you should use the modifier 59 to represent completely separate treatments.

Another medical billing guideline for modifier 59 is to use it in relation to group therapy sessions. It is perfectly fine to bill for a one-on-one therapy session AND a group therapy session if the two meet the Current Procedural Terminology definitions. The one difference is that you will bill using the medical billing modifier 59 for the group therapy and not for the one-on-one session.

It is important for your practice to do what ever it can to fly under the radar of CMS. The Centers for Medicare and Medicaid Services should not be crossed. Teaching your medical billing staff the correct way to use modifier 59 will save the United States government some money, and your practice some auditing stress.

View all Articles by: Melissa Clark, CCS-P