Modifier 59 Explained

Usage of modifiers is tricky, and modifier 59 is no exception. This modifier can be used for a procedural service if it is distinct and separate from another procedure that is performed on the same date of service. This modifier is usually applied to a procedure code. It must be used in instances that are typically not remunerated separately from the first procedure and depend on the specifics of the circumstances.

Cases where modifier 59 dental billing can be used are as follows:

• Unique encounter or session on the same day when treatment is rendered
• A procedure that is separate and distinct from the first procedure
• Separate anatomic site
• Separate injury, excision, or incision

It must be noted that modifiers 59 and 51 apply to supplementary procedures undertaken on the same day as the primary procedure was undertaken. Modifier 51 can be applied to different procedures on different sites.

What guidelines need to be known

When two services that are usually bundled need to be billed separately, modifier 59 dental billing can be used by the team. The team refers to CCI edits to verify if two codes can be bundled.

Two codes are termed mutually exclusive or paired together as “column 1” and “column 2” codes within CCI and are bundled and not typically reported separately.

Each CCI code pair edit includes a correct coding modifier indicator of zero or one. A ‘zero’ indicator implies that the dental team is not allowed to unbundle the edit combination. A ‘one’ indicator denotes that modifier 59 can be used to overturn the edit if both are clearly distinct procedures.

What are the three conditions where modifier 59 will always apply?

The three conditions, as per CCI Chapter 1 guidelines, that allow usage of modifier 59 are as follows:

• The practice may need to undertake a diagnostic procedure before a surgical or non-surgical therapeutic procedure. Now the outcome procedure can form the basis for whether the practice will decide between a surgical or non-surgical therapeutic procedure. In such cases, a diagnostic procedure can be termed a separate and distinct procedure.
  The only conditions, however, are that: 1) the diagnostic procedure must be done before the therapeutic procedure. It cannot be combined with services needed for therapeutic intervention. 2) The information on whether to proceed with the therapeutic procedure based on the diagnostic procedure has been clearly outlined. 3) The diagnostic procedure would not be needed during the therapeutic intervention. If the diagnostic procedure was required during the therapeutic procedure, then reporting it separately is not permitted.
• Based on the patient’s condition, a diagnostic procedure might be recommended after a therapeutic procedure. This can be termed a distinct procedure. The conditions, however, for modifier 59 to be used are: 1) The diagnostic procedure needs to be done after the therapeutic procedure is over. 2) The diagnostic procedure was not supposed to take place during the therapeutic procedure. If there was an inherent need for the diagnostic procedure to be a part of the therapeutic procedure, then the dental team cannot consider the diagnostic procedure as distinct or separate.
• Modifier 59 can also be applied to codes for which the unit of service is a duration of time. One can consider a lot of fifteen minutes in an hour. If the practice needs to undertake two distinct and separate timed services and gets performed in separate and distinct time blocks, the dental team can use modifier 59 to identify the services.
  The time blocks can be sequential to one another or even split. If the services or procedures are split, the time block for one procedure can be followed by a time block for the other procedure. The dental team must adhere to prevailing Medicare rules for reporting timed services.

When should Modifier 59 be used?

Billing for two services or procedures that form an NCCI edit pair

If the dental practice performed two services independently of each other, the team could use modifier 59 to identify the procedures or services. The team must ensure that the documentation supports a different session or procedure or surgery, different sites, separate incisions, or separate injuries not regularly performed on the same day on the same patient.

Modifier 59 pertains primarily to surgical procedures, with a reference to lesions, excisions, or incisions. However, modifier 59 can also be applied in combination with a rehab therapy service. The team must refer to NCCI edit pairs to detect such instances.

Edit pairs or linked services are sets of services or procedures that dental practitioners are likely to perform together based on the patient’s situation. When the dental team completes a claim submission to an insurance firm comprising both codes in an edit pair, the practice will get reimbursement for only one procedure. The insurance company assumes that one service or procedure was built into the other.

There is a possibility that the practice did not perform the two procedures or services together. This is where the dental team needs to append modifier 59 to one of the codes in an edit pair. This acts as a signal to the insurance company that the practice provided both services in the pair independently of each other. The practice then gets reimbursed for both services.

Edit pairs recognized by different insurance companies

The dental team needs to understand that different insurance companies might adhere to different sources for recognition of edit pairs. Medicare adheres to edit pairs based on NCCI, while other insurance firms might not. Some private insurance players can refer to a combination of NCCI/CCI edits. Some insurance companies adopt a set of proprietary edit pairs to decide on coverage.

To avoid any claim denial, the dental team needs to use modifier 59 appropriately and check with the respective insurance company before commencing any procedure or service.

When the team can provide documentation that supports the claims

The dental team can complete billing the service that was rendered to the patient by using the correct codes and modifiers. But even this approach could have limitations. There are times when the practice needs comprehensive, defensible documentation, should the need arise.
It is this documentation that can justify the usage of modifier 59 and the claim submission.

These notes and narratives help the practice to substantiate decisions made by the practice for undertaking recommended procedures for the patient.

Lack of a more descriptive modifier

It is recommended that modifier 59 should be used only if no other modifier explains the recommended action by the practice. There are new modifiers such as XE, XS, XP, and XU that can bypass a CCI edit. The dental team might have to use such modifiers in the future.

Modifier 59 must be used to represent the procedures performed by the practice accurately.
It can be applied when the dental team needs to report two procedures or services that are usually bundled.