Recently, we were told that we could be using a 59 modifier on same site multiple surgical procedures. Other orthopaedic practices indicated that they have been doing this for quite some time. Our coder does not believe this is legal. The manuals we have are confusing on this issue. Can you provide any information on this matter or refer me to someone who can assist us in this matter? Thank you. Jim

Jim,
According to the CPT manual, modifier 59, Distinct Procedural Service, is used in special circumstances, to indicate that a procedure or service was distinct or independent from other services performed on the same day.

Modifier '-59' is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent :

• a different session or patient encounter,
• different procedure or surgery, different site or organ system,
• separate incision/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.

The following example shows when it modifier 59 is appropriate:

Appropriate use of Modifier 59:
According to the AMA and AAOS, CPT code 29877 is the appropriate CPT code to report when a physician performs a chondroplasty in a separate compartment from meniscal surgery. In this scenario, the modifier indicates a separate compartment (different site). The only circumstance when a chondroplasty may be reported in addition to meniscal surgery is when the chondroplasty is in a different compartment. The modifier 59 in this case indicates the different anatomic location. A modifier 51, Multiple Procedure would not explain to the payor that the chondroplasty was in a different compartment.

Example of when Modifier 59 is not appropriate:
Physician performs an ACL reconstruction and a lateral meniscectomy. These are two separate procedures, and while both in the knee are recognized as two separate anatomic locations. The most appropriate modifier is modifier 51.

I hope this helps somewhat. You do not want to use modifier 59 if there is a modifier to describe the special operative circumstance. Overuse can be a concern, but if you are using appropriately, the concern is minimized.

Mary LeGrand, RN, MA, CCS-P
KarenZupko & Associates, Inc.