BILLING BASICS: Red-Flag Alert! CMS Puts the Squeeze on Modifier -59

Don't unbundle without rock-solid documentation

If you're indiscriminately using modifier -59, you may get your claims paid - but you could be asking for trouble with potential audits and big penalties.
 
To avoid running afoul of CMS regulators, always be sure the physician's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59  (Distinct procedural service).
Don't Treat -59 as a Catchall
You should never use modifier -59 if another modifier - or no modifier at all - will tell the story more accurately.
 
CPT guidelines clearly indicate that "the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant. In other words, -59 is the modifier of last resort.
 
Coding example: For treatment of a Medicare patient, the physician performs an excisional breast biopsy (19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions) in an outpatient clinic, which returns positive. Later that afternoon, he performs a modified radical mastectomy (19240, Mastectomy, modified radical, including axillary lymph nodes,
with or without pectoralis minor muscle, but excluding pectoralis major muscle).
What NOT to do: The National Correct Coding Initiative (NCCI) bundles 19120 to 19240, but in this case you are justified in seeking additional compensation because the physician's documentation indicates that the biopsy results led to the decision to perform the mastectomy (and therefore the excisional biopsy is separately payable).
 
You should not turn to modifier -59 in this situation, however (even though the insurer might pay the claim).
What to do instead: In this case, a different modifier, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), better describes the circumstances. Therefore, you should report 19120, 19240-58. The payer should recognize the separate nature of the mastectomy (as described by modifier -58) and reimburse accordingly.
Don't Unbundle Without Cause
Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get reimbursement.

"[Modifier -59] is overused just to get through the edits," says consultant Annette Grady, CPC, CPC-H, with Eide Bailly in Bismarck, N.D.
Indeed, coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
But Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation [...]

- Published on 2005-02-12