Appropriate Use of Modifier 59

June 3, 2011

On May 2, 2011, Blue Cross and Blue Shield of Texas (BCBSTX) implemented ClaimsXtenTM, a code auditing tool developed by McKesson Information Solutions, Inc. Modifier-to-procedure validation edits were added into our auditing logic with the implementation of ClaimsXten. BCBSTX will now request a corrected claim when it is determined, based on correct coding guidelines, that an inappropriate modifier was appended to a CPT®’ or HCPCS code.

Modifier 59 is used to report that a service is a distinct procedural service. Based on the definition of modifier 59, it would be inappropriate to append modifier 59 to non-procedural services. Non-procedural services would include, but are not limited to, HCPCS codes for surgical supplies, including surgical trays (HCPCS code A4550). 

Clear Claim ConnectionTM (C3) will continue to be the provider resource that allows disclosure of claim auditing rules and clinical rationale to the BCBSTX contracting provider network. C3 is a free online tool available to providers who are registered with Availity®’ and/or RealMed®.

Learn more about C3 and view the ClaimsXten Frequently Asked Questions (FAQs) .

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc.

Current Procedural Terminology (CPT®’), copyright 2008, by the American Medical Association (AMA). CPT is a registered trademark of the AMA.

Availity is a registered trademark of Availity, L.L.C. RealMed is a registered trademark of RealMed Corporation, an Availity Company.

McKesson Information Solutions, Inc., Availity, L.L.C. and RealMed Corporation are independent third party vendors and are solely responsible for their products and services. BCBSTX makes no representations or warranties regarding the products or services provided by either of these vendors. If you have any questions regarding the products or services provided by these vendors, you should contact the vendor(s) directly.