Reminder: Modifier 59

Remember to submit medical records when using modifier 59 on four or more claims lines. If modifier 59 is appended to more than four services, the claim will suspend to allow manual review of lines appended with modifier 59 when attachments are included; otherwise, each service appended with modifier 59 will be denied for lack of supporting documentation. 

As modifier 59 is indicative of a distinct and separate service, more than four procedures reported with modifier 59 are examined for the additional services provided.

If you receive a denial related to this policy and disagree with the payment determination, don’t resubmit your claim or use the Medical Record Routing Form process. Instead, follow the Clinical Editing appeals process outlined below and include medical records. 

• Appeals must be submitted with a Clinical Editing Appeal form. All required fields must be completed or the appeal will be returned to you. This form is available on the Blue Cross Blue Shield of Michigan provider site and in the provider manual on web‑DENIS.
• Submit the form one of the following ways:

Fax: 1‑866‑392‑7191

Mail: Clinical Editing Appeals
Mail Code G820
Blue Cross Blue Shield of Michigan PPO
611 Cascade West Parkway, SE
Grand Rapids, MI 49546-2143

Appeals must be submitted within 180 days of the original clinical editing denial. Documentation supporting the appeal must be submitted with the appeal.

Documentation requirements may vary depending on the service being appealed. As examples:

• Office services that have denied may require office notes.
• Services denied as duplicates will require records for both the denied and paid service to show that more than one was performed.
• Surgical denials may require operative reports.

It’s important to look at the denial reason and submit documentation appropriate to the procedure code that was denied and the reason for denial.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.