Knowledge Base Article

Q:

Sometimes modifier 59 is still confusing to us when we are trying to work through CCI edits for Medicare. Is there any new information about modifier 59 that can help us better understand?

A:

Correct Coding Initiative edits are still referred to by a lot of people as “CCI edits”, so we know exactly what you are talking about. Instead of CCI edits, CMS now refers to these as “Procedure to Procedure” edits (PTP). It’s a different name, but the concept is still the same, and hospitals still have to “work through” – as you say – all these edits to determine when to add a modifier.

In March 2020, CMS released a MLN Matters Article SE1418 regarding the proper use of modifier 59 and modifiers –X{EPSU}. In my opinion, the article includes helpful examples of separate practitioner, structure, and encounter.

You asked about Modifier 59, but as you read through the MLN article, you will also see examples for using the X{EPSU} modifiers instead of modifier 59. Remember, the X{EPSU} modifiers are considered more specific than modifier 59 and should be used in lieu of modifier 59 whenever possible. Be sure to incorporate all of this information into your efforts when deciding if a modifier is needed.

I doubt anyone will ever have all the answers about modifier 59, and I say this based on the number of related inquiries we receive every week. With over 1 million code pairs involved, it’s no wonder there’s ongoing confusion.