- Anesthesia Modifiers
- Appropriate Usage of Modifier 99
- Assistants at Surgery at Teaching Hospitals
- Bundled Services Missing Appropriate Modifiers at Time of Initial Claim Submission
- Clarification for Billing Services on Fingers and Toes Using Modifiers F1-F9, FA, T1-T9 and TA vs. Modifier 50
- Correct Usage of Modifier 79 for Multiple Procedures
- Co-Surgery/Team Surgery/Assistant Surgery Modifiers
- Modifier 25
- Modifier 33
- Modifier 51
- Modifier 52 Claim Submission Billing Reminder
- Modifier 59 and the Subset Modifiers XE, XP, XS, XU - Specific Modifiers for Distinct Procedural Services
- Modifier 90 Reference to Outside Laboratory
- Modifiers
- Modifier Usage
- Proper Billing of Surgical Comanagement (Modifiers 54 and 55)
- Proper Use of Modifiers 59 and 91
- Reminder for Submission of Modifier 22
- Repeat Procedures - Modifiers 76 and 77
Proper Use of Modifiers 59 and 91
Table of Contents
Modifier 59
Claim submissions and redeterminations received by National Government Services indicates a large volume of claims denying for incorrect usage of modifier 59.
Modifier 59 is defined as a “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 or 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 or 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 physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Note: Modifier 59 should not be appended to an E/M service performed on the same date, see Modifier 25.
Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.
Appropriate Usage
- Represented by a different session or patient encounter, different procedure or surgery, different anatomical site, or separate injury or area of injury
- Medical record documentation indicates two separate distinct procedures performed on the same day by the same physician
- May be used on either the Column 1 or Column 2 code listed in NCCI edits
- Only when there is no other appropriate modifier to use
Inappropriate Usage
- Code combination does not appear in the NCCI edits
- Not be appended to an E/M service performed on the same date, see modifier 25
- MPFSDB lists the procedure code with a modifier indicator of "0"
- The medical record documentation does not support the separate and distinct status
- The exact same procedure code was performed twice on the same day (see Repeat Procedures - Modifiers 76 and 77)
- If a valid more appropriate modifier exists to identify the services
Modifier 91
Modifier 91 is used to indicate a repeat laboratory procedural service on the same day to obtain subsequent reportable test values. The physician may need to indicate that a lab procedure or service was distinct or separate from other lab services performed on the same day. This may indicate that a repeat clinical diagnostic laboratory test was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain subsequent reportable test values.
Multiple laboratory services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because these circumstances cannot be easily identified, modifier 91 was established to permit claims of such a nature to bypass correct coding edits. The addition of this modifier to a laboratory procedure code indicates a repeat test or procedure on the same day.
Appropriate Usage
- Identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test
Inappropriate Usage
- Due to testing problems for the specimen or testing problems of the equipment
- Rerun of a laboratory test to confirm results
- When the procedure code describes a series of test
Additional Information
- Modifier 91 does not replace modifiers such as RT, LT, 50, E1-E4, FA, F1-F9, TA, and T1-T9.
- If billing a procedure code two or more times for the same date of service, the claim should be submitted with the procedure code listed on one line without modifier 91 and each subsequent procedure listed on a separate line using the modifier 91.
Related Content
- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1
- MLN® Fact Sheet: Proper Use of Modifiers 59 & -XE, XP, XS, XU
- NCCI listings on the CMS website
Revised 10/16/2024