Medical Billing Forum

Billing => Billing => : jcbilling June 23, 2009, 12:32:31 AM

: -59 Modifier Usage
: jcbilling June 23, 2009, 12:32:31 AM

I just recently started billing for a family practice and am trying to learn when the -59 modifier is necessary.

My understanding is that the -59 modifier is used when there is an office visit with at least 2 other procedures, assuming that the procedure was not in a CCI Pair.

For example,

99214 - 25
82962
81000 - 59
93000 - 59

Is that correct? And is this modifier required for commercial carriers or just Medicare?

Thanks so much,
Charity

: Re: -59 Modifier Usage
: Michele June 23, 2009, 09:19:16 AM

The 59 modifier is not used based on the number of codes being billed, but rather on whether or not codes would normally be bundled.  If you are billing for two services where one is considered inclusive of another, but there is a reason that it should be allowed separately you would use the 59 modifier.  In the example you gave, you should not need a 59 modifier on the 93000 (EKG) because the EKG is not considered inclusive of any of the other procedures being billed and should therefore be allowed separately without a modifier.  The same with the 81000.  An example of when the 59 modifier would be used:

99213     724.2    401.0   250.00    (office visit for low back pain, HTN, & DM)
90804  59  304.00   (along with a 20-30 min counseling for opioid dependency)


With all that said, the insurance companies are going to do what they are going to do and sometimes modifiers are needed when they shouldn't be.

Hope that helps
Michele

: Re: -59 Modifier Usage
: jcbilling June 26, 2009, 04:28:56 PM

Michelle,

Is there a list of bundled codes somewhere for reference? I'm not very famaliar with the codes I'm working with and am trying to figure out when it would be needed.

Thanks,
Charity

: Re: -59 Modifier Usage
: Michele June 30, 2009, 11:28:38 PM

I'm not aware of any list since bundling varies from carrier to carrier.

Michele

: Re: -59 Modifier Usage
: rachel July 07, 2009, 01:58:08 PM

in regards to modifiers, does the dr's office advise which to use if you are striclty handling there billing?

: Re: -59 Modifier Usage
: Michele July 08, 2009, 12:04:14 AM

Some doctors will give you the modifiers, some do not understand how they are supposed to be used.  As a biller you should not just decide what modifiers to use and use them, but you should sit down with the dr and go over the services he bills for and advise him what modifiers would be appropriate and what they mean so he can tell you if that accurately describes what he is doing.

Michele