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Claim Payment Policy
| Title: | Modifier 59: Distinct Procedural Service |
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Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.
In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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 Intent |
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The intent of this policy is to communicate the Company's reporting requirements for Modifier 59: Distinct Procedural Service.
For information on policies related to this topic, refer to the Cross References Table in this policy. |
| Description |
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Under certain circumstances it may be necessary to indicate that a procedure or service is separate, distinct, or independent from other non-evaluation and management (E&M) services performed on the same day by the same individual. These circumstances may be reported by appending Modifier 59: Distinct Procedural Service to the applicable procedure code.
The addition of Modifier 59 to a procedure code indicates that the procedure represents a different:
- Session
- Procedure or surgery
- Anatomic site or organ system
- Lesion, through a separate incision/excision or for a separate injury or area of extensive injuries
- Procedure not ordinarily encountered or performed on the same day by the same individual
Modifier 59 should only be reported when it is the most accurate modifier that is available to describe the circumstances of the procedure or service. |
| Policy |
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The Company has established the following requirements for the appropriate reporting of Modifier 59: Distinct Procedural Services:
- When services are performed on the same day but at a different session
- When services are performed at the same session but at a different anatomic site or organ
- When services are performed on different lesions through a separate incision/excision or for a separate injury or an area of extensive injuries
- When procedures performed are procedures that are not ordinarily encountered or performed on the same day by the same individual
- When there is no other modifier that describes the situation more accurately
Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
REQUIRED DOCUMENTATION
The member's medical record must contain the supporting medical necessity documentation describing the circumstances precipitating the performance of the subsequent procedure or service. The member's medical records must be made available to the Company upon request. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agency, other health care professionals, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. Claims submitted with Modifier 59: Distinct Procedural Service are subject to post-payment clinical review and potential retractions for inappropriate use. |
| Guidelines |
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Supporting medical necessity documentation must be maintained in medical records and made available to the Company upon request.
The following are inappropriate uses of Modifier 59:
- When it is appended to evaluation and management (E&M) procedure codes
- When it is used as a replacement for Modifiers 24, 25, 78, or 79
- When it is used when another modifier best describes the service
- When it is reported with Modifier 51 on the same procedure code
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| References |
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Beebe M, Dalton JA, Espronceda M, Evans DD, Glenn RL, eds. Current Procedural Terminology: CPT 2008 (Professional Edition). Chicago, IL: AMA Press; 2007.
Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 23: Fee schedule administration and coding requirements. [CMS Web site]. 03/06/08. Available at:
http://www.cms.hhs.gov/manuals/downloads/clm104c23.pdf. Accessed June 10, 2008.
Highmark Medicare Services. Medicare Part B Reference Manual: Appendix C - Correct coding combinations. [Highmark Medicare Services Web site]. Available at: http://www.highmarkmedicareservices.com/partb/refman/appendix-c.html#6. Accessed June 10, 2008. |
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| Coding Table |
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Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company. |
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| Code System | Code Number(s) and Narrative(s) |
| CPT | N/A |
| ICD Procedure | N/A |
| ICD Diagnosis | N/A |
| HCPCS Level II | N/A |
| Modifier | Modifier 59: Distinct Procedural Service |
| Revenue Codes | N/A |
| Cross References |
| Cross Reference Policies |
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| Version Effective Date: 09/22/2008 | |
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The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2012 AmeriHealth, Inc. All Rights Reserved. Current Procedural Terminology ©2012 American Medical Association. All Rights Reserved. |
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