Question: A physician in our outpatient clinic performed an excisional breast biopsy in an outpatient clinic. Later that afternoon, he performed a modified radical mastectomy. Should I use modifier 59 when I report these procedures?
Missouri Subscriber
Answer: No, you should not use modifier 59 (Distinct procedural service) in this scenario. The National Correct Coding Initiative bundles 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) into 19240 (Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).
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), but modifier 59 isn’t your best option.
In this scenario, 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.
Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
