The Problem with Modifier 59: Open to Interpretation

Modifier 59 is shockingly confusing for coders, auditors and physicians alike. It’s frequently misused, for example, it’s often added as prevention or recoupment of an insurance denial as a way to get additional procedures paid. When I see this I just want to leap from my desk and scream, “no!” from the rooftops. While I fully support getting paid for the work that’s been done, there are a few reasons why using Modifier 59 is totally wrong.

There are a number of rules within Modifier 59, that are open to interpretation. For example:

“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.”

Coders and providers alike tend to misunderstand the usage of this modifier, even if they have the definition memorized. The rules for different procedure or surgery, different site or organ system, separate lesion, or separate injury can be easily interpreted differently. They become especially confusing when different logic might apply to different chapters within the surgery section of CPT. My advice is to treat each individual occurrence as its own equation. In difficult cases, discussions between coders and clinicians can prove to be extremely helpful in shedding light on what exactly was done in the operating room (and, consequently, how that procedure is reflected in the documentation). Oftentimes, the documentation requires a bit of tweaking to ensure specific landmarks or other determining factors are clearly stated.

To learn more, download our free eBrief, Your Guide to Clarifying Modifier 59, to clear up confusion and increase audit accuracy. You’ll learn how to use Modifier 59 correctly, talk to doctors for increased accuracy and master X Modifiers.