Modifier 59, 62, 66

Modifier 59 : Distinct Procedural Service

Instructions

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 

Documentation must support a different session, 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 individual.

Correct Use

Different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

• Procedures are performed in different encounters on the same day
• Two services described by timed codes provided during the same encounter only when they are performed sequentially
• Diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
• Diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure

Incorrect Use

• Should not be appended to an E/M service
• Should not be used inappropriately if the basis for its use is that the narrative description of the two codes is different
• When another modifier is more appropriate (e.g. modifier 76 or 91)
• Should not be used to bypass NCCI edits
• Does not replace modifiers such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI

Example

Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable.

This claim example shows CPT 17000 with no modifiers on the first claim line and CPT 11100 with modifier 59 on the second claim line.

Note: If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Reminders

Records must evidence a different session or patient encounter, different procedure or surgery, different site or organ system, or separate lesion, incision, excision, injury or area of injury

Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.

Modifier 62

Two Surgeons. The individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition and the additional physician is not acting as an assistant at surgery. 

If the two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62.

Instructions

Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (e.g., heart transplant or bilateral knee replacements). 

Documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Physician Fee Schedule Database (MPFSDB).

If the surgery is billed with a modifier 62 and the indicator is 1, the claim will suspend for manual review of any documentation submitted with the claim. If the surgery is billed with a modifier 62 and the indicator is 2, then the payment rule for two surgeons apply.

Correct Use

• Both surgeons must agree to append modifier 62 on their claim
• Reimbursement at 62.5% of MPFSDB
• Indicator in MPFSDB must be either 1 or 2
• Procedure code and diagnosis code should be same
• Billed amount might not be same

Incorrect Use

Modifier 62 must be on both claims or one physician will be paid at 100% and other physician's claim will deny

Both surgeons must use same CPT code

Claim Coding Example

Dr Smith and Dr Jones (both orthopedic surgeons) performed as co-surgeons an Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure). Co-surgery Indicator 2.

Date CPT/Modifier Charge Units

02/20/2016 24006 62 $825 1

Date CPT/Modifier Charge Units

02/20/2016 24006 62 $1025 1

Allowance based on 62.5% of the allowable for code 24006 for both surgeons. No documentation needed. So if the allowance is $752.04, then 62.5% of this amount is $470.03 for each surgeon.

Modifier 66 : Team Surgeons – Surgical Team

Instructions

This modifier states a single, highly complex surgery or procedure that requires several physicians from the same or different specialties.

Correct Use

Includes other highly skilled and specially trained personnel

Includes different types of complex equipment 

Usually confined to organ transplant teams

Reimbursed "by report"

Medicare Physician Fee Schedule (MPFS) Indicator List

"T" column indicator 1 or 2 

Claim subject to Medical Review and documentation will be requested  

Every surgeon MUST append modifier 66 to the CPT code      

Incorrect Use

Not appropriate for two or less surgeons

Claim Coding Example

Treatment Description : Renal allotransplantation, implantation of graft; with recipient nephrectomy

CPT 50360 /Modifier 66