Modifier 51 and Modifier 59: What to exclude and include in its application?



Modifiers are of utmost importance when you want to tell the story of a claim by identifying procedures that have been altered, without even changing the core meaning of the code(s) that has been submitted. This article will expound on the proper and accurate application of modifiers 51, and 59.

There are some crucial steps for applying modifiers correctly. Looking at the CPT guidelines should be one of the places we will always go, of course, reviewing the payer guidelines because no one accepts every modifier.

And even if they do accept them, they might accept them in a little bit different of a context than what CPT does. So, you will always want to go to your payers and see how they look at or how they accept those modifiers.

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We have been shown to not use modifier -25, modifier -59 very appropriately. So, those modifiers tend to get looked over sometimes. So, brush up your coding skills with our latest healthcare modifier articles.

Of course, not at every single note that goes out the door, but take a look and spot check some of them where you're using modifiers to make sure the documentation is going to hold up if it gets asked for.

We can only use the two-digit modifiers now. We can't make the long modifiers like we used to. We can't make the five-digit modifiers. So, take a look at the NCCI, the edits for bundling that are out there to make sure that we can append the modifier to what we are coding or if it would be considered unbundling if we try to bill a couple of things together.

The modifiers that we probably are mostly going to use are the -51 and the -59. If your physician is excising and then doing closures or you're doing the modes and then they're coming to do closures later, you may need to also use modifier -58 a lot because you're in the global period and you want to show or state what's being done.

With modifier -59, just make sure you follow the procedure and the NCCI edits to ensure it's appropriate to bypass the edit with the modifier, and to look in the back of your CPT book.
If you're looking for -59, it's because of an NCCI edit. So, be judicious with your application of modifiers. But if you need it to get paid and it's appropriate, never be afraid to put one of those modifiers on your claim form.

The 51 modifier exists to let the carrier know that there is more than one procedure (multiple procedures performed) (not used in some settings, depends on who you are billing for). Whereas, the 59 modifier is used to let the carrier know it’s a separately identifiable different location/site.

For instance, you are having the same procedure done on two different toes. The CPT code is not any different. You would always want to identify the 2nd code with the 59 modifier otherwise they bundle them.
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