News and Publications

CMS issues guidance on proper use of modifier 59

May 22, 2019

The Centers for Medicare and Medicaid Services (CMS) issued guidance on the proper use of modifier 59 (Distinct Procedural Service) in a May 17, 2019, Medicare Learning Network (MLN) Connects transmittal. When used appropriately, modifier 59 indicates that, due to special circumstances, two codes that are not normally reported together on the same date of service (by either National Correct Coding Initiative (NCCI) edits or CPT guidelines) can be billed for that encounter. Since the improper use of modifier 59 can lead to potential increases in payments, its use is watched closely. An OIG report (pdf) found that "forty percent of code pairs billed with modifier 59 did not meet program requirements, resulting in $59 million in improper payments." The report further stated that "25 percent of the code pairs billed with modifier 59 were not adequately documented." A review of the revised MLN Matters article provides an opportunity to refresh yourself on the rules for proper use of modifier 59 to ensure that you are reimbursed appropriately for services provided.