When to Use

Use Modifier 59 when:

• Two procedures are performed that are normally bundled under NCCI edits
• The procedures are distinct because they involve:

• Different anatomical sites

• Separate incisions

• Separate encounters

• Separate lesions
  • No more specific X modifier (XE, XS, XP, XU) applies
  • Documentation clearly supports distinct services

In the facility outpatient setting, Modifier 59 is commonly used to bypass an NCCI edit when services are appropriately separate under CMS rules.

When Not to Use

Do NOT use Modifier 59 when:

• A more specific modifier applies (XE, XS, XP, or XU)
• The procedures are integral to each other
• The services are components of a comprehensive service
• Documentation does not clearly support separation
• It is being used simply to obtain payment

Modifier 59 should never be used to override edits without documentation support.

Common Denial Reasons

• Documentation does not support two distinct encounters
• Patient was never discharged between visits
• Second visit is related and continuous with first visit
• Modifier appended to physician claim instead of facility claim

Real-World Example

A patient presents to a hospital outpatient clinic for a scheduled follow-up in the morning.

Later that same day, the patient develops chest pain and presents to the emergency department.

If both visits are separately documented and medically necessary, the hospital may append Modifier 27 to the second E/M service.

CMS Guidance

CMS allows Modifier 27 to identify multiple outpatient hospital E/M encounters on the same date.

Key CMS principles:

• Applies to hospital outpatient claims only
• Not reported by physicians
• Encounters must be distinct and medically necessary
• Documentation must support separate visits

Modifier 27 is recognized under the Outpatient Prospective Payment System (OPPS).