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CPT for ENT: Modifier 59 Scrutinized

CPT for ENT: Modifier 59 Scrutinized

The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. 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. Plainly stated, modifier 59 is used to bill procedures performed on the same date of service that represent a:

  • different session or patient encounter
  • different procedure or surgery
  • different site or organ system
  • separate incision/excision or lesion
  • separate injury (or area of surgery in extensive injuries)

Physicians should only use modifier 59 when there is no other modifier more appropriate. You generally append modifier 59 to the lesser service(s) but the designation of which code of a code-pair is assigned the modifier is defined by the National Correct Coding Edits (NCCI). There has been some controversy over proper use of the 59 modifier, and otolaryngology offices have had trouble determining when it is appropriate to use the 59 modifier. Adding to this trouble is recent “monitoring” of the use of this modifier by private insurance carriers and the Centers for Medicare and Medicaid Services (CMS). At this writing, CMS is considering a new set of modifiers to supplant the 59 modifier, but they have not been implemented.

Make sure that when filing claims with the 59 modifier, your documentation supports its usage as a separate and distinct procedure. Remember, modifier 59 is not intended to report procedures that took extra time or were performed to facilitate or provide access to a primary procedure that was done. If you’ve met all of the above requirements, modifier 59 can be used to differentiate services.

Reviewed July, 2006
Revised April 2016

Important Disclaimer Notice (Updated 8/7/14)
CPT for ENT articles are a collaborative effort between the Academy’s team of CPT Advisors, members of the Physician Payment Policy (3P) workgroup, and health policy staff. Articles are developed to address common coding questions received by the health policy team, as well as to clarify coding changes and correct coding principles for frequently reported ENT procedures. These articles are not intended as legal, medical, or business advice and are not a guarantee of reimbursement. The information is also not meant to serve as the definitive or sole authority on billing and coding issues. The applicability of AAO-HNS billing and coding guidance for a particular procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. You should consult with your own advisors as well as Medicare or private carriers in making any decisions about how to bill and code particular services or procedures.

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