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Coding Corner: When to use and not use modifier 59



February 01, 2012
Area(s) of Interest: Payor Issues and Reimbursement Practice Management Professional Development & Education 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from the Director of Educational Development for AAPC, John Vehovshek, MA, CPC.


Before appending modifier -59 to override a Correct Coding Initiative (CCI) edit, you must be certain that unbundling is allowed for the particular code pair you wish to report as separate/distinct procedures.


Each CCI code pair edit includes a correct coding modifier indicator of “0” or “1,” as indicated by a superscript placed to the right of the column 2 code. A “0” indicator means you may not unbundle the edit combination under any circumstances. An indicator of “1” means you may use a modifier to override the edit if the procedures are distinct from one another.


For example, “CPT 11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less” is mutually exclusive of “CPT 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia); simple or single),” according to the CCI edit.


Code 11400 is the “column 1” (more extensive) procedure. For incision and drainage and lesion excision at the same location, report only 11400 because 10060 is bundled to the excision. This code pair contains a “1” modifier indicator, however, and you may dismiss the edit if the procedures are distinct from one another. For instance, for incision and drainage and lesion excision at different locations, you would report 11400 and 10060-59. Note the placement of 59 on the “lesser” procedure.

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