Code Designations Determine When to Use Modifier 59

When do I use medical billing modifier 59?
This is a great question. It is one that many don’t ask, but most don’t know the correct answer to. One of the most important things to know about the medical billing modifier 59 is which code on which to append it. There are some basic medical billing rules that can teach you which code to use with modifier 59.

The general assumption about modifier 59 (Distinct procedural service) is that it should be linked to the lower-valued code of the pair. Although this may be true a lot of times, it is not always true. There is a much better rule to follow to have correct medical billing documents.

The better rule to use with the medical billing modifier 59 is to append it with the component code, or the code in column two. The NCCI (National Correct Coding Initiative) code list consists of different edits with two types of codes. The edits have columns. One column is the comprehensive column, and column two is the medical billing component column. If on the same day, you report from both columns, the Centers for Medicare and Medicaid Services will only reimburse for the first column.

The medical billing modifier 59 should be used if you bill from both columns on one date of service. You should always append the modifier to the code in the second column. This will ensure correct medical billing reimbursement. Many times this is the lower valued code, but not always – as always with medical billing, it’s usually a judgment call based on other factors in the medical billing claim.

View all Articles by: Melissa Clark, CCS-P