April 2010

Appropriate use of Modifier -59

Asuris recently conducted a coding review of medical records to assess the use of CPT Modifier -59. Our review found inappropriate use of Modifier -59 Distinct Procedural Service. Based on these findings, Asuris will not allow Modifier -59 to bypass certain NCCI and CCE code pair edits effective July 1. Therefore, as of this date, certain codes found in NCCI and CCE code pair edits, which have been paid in the past when billed with a Modifier -59, will be denied.

This change in NCCI and CCE bypass logic does not preclude Asuris from denying claims with dates of service prior to July 1 where Modifier -59 was not properly assigned.

According to CPT guidelines, use of Modifier -59 is limited to the following:

Under certain circumstances to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E&M) services performed on the same day
To identify procedures or services, other than E&M services, not normally reported together but are appropriate under the circumstances

You can find the code pairs where Modifier -59 will not result in a code pair edit bypass in our Asuris CCE. Our CCE is updated on a quarterly basis (January, April, July, October). Additional code pairs that Modifier -59 will not bypass may be added to the list as they are identified.