Procedure Code Pairs and Modifiers
Some payers will not allow certain procedure code pairs to be billed together during the same visit. They may exclude one of the two codes, or bundle the codes together and pay for the combined time spent on both procedures under one of the procedure codes. The payer may allow the use of a CPT Code Modifier to override the exclusion of one of the codes or bundling of the code pairs. The -59 modifier may be applied, when allowed, to indicate to the payer that the codes should be paid separately. The documentation should support the application of the modifier. If, for example, a -59 modifier is being applied, the documentation should clearly indicate that separately identifiable clinical procedures were performed during the visit.
For example, let’s say the payer would normally exclude 97110 when performed at the same visit with 97530, but they allow a modifier to override the procedure code pair ruleset.
Without the modifier applied, the codes would be aggregated as illustrated here:
With the modifier applied, the codes would be aggregated as illustrated here: