CMS Sees Trend of Inappropriate Use of Modifier 59 for Multiple Services

CMS has seen a trend among providers billing for multiple services of the same procedure code. Specifically, some providers are submitting the same CPT/HCPCS on multiple lines with units of service “1” on each line and billing each line with a modifier 59.  Please be aware of the following considerations when billing in this manner:

• Modifier 59 is a modifier of last resort and should only be used when there is no other modifier that would fit in a NCCI or MUE situation. Outside of the NCCI and MUE edits, modifier 59 serves no purpose.
• If billing for multiple units of the same service, billing guidelines indicate that the multiple services would be billed on one line with one procedure code, and the number of units indicating the number of times it was performed that day on the claim line.
• Billing a single claim line for each unit of service under the same procedure code will only cause the system to deny each line after the first as a duplicate charge.

If you have received duplicate denials for billing in this manner, please ensure you correct your billing on any future submissions.  You will also need to appeal any claims that contained services that were denied and should have been paid if they were filed correctly.

Make sure you update your NCCI edit books quarterly or purchase a software program that shows you column one and column two edits.

Remember, modifier of last resort.