Anesthesia Coding Alert

When your physician performs two medically necessary procedures during the same session, knowing the ins and outs of modifier 59 is essential for your coding.

The problem: Modifier 59 (Distinct procedural service) is one of the most misunderstood modifiers. Avoid problems -- and get your claims paid -- by following these proven tips:

The Office of Inspector General (OIG) and many payers, including Medicare, continually review physicians' modifier 59 use.

There are circumstances when you can -- and should -- use modifier 59, however. For instance, you may use modifier 59 to identify procedures that are distinctly separate from another procedure provided by your physician on the same day. In addition, you may append 59 to your claim when your physician: sees a patient during a different session, treats a different site or organ system, makes a separate incision/excision, tends to a different lesion, and treats a separate injury.

Example: Your anesthesiologist assists on a lung resection with one lung ventilation (00541, Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum [including surgical thoracoscopy]; utilizing 1 lung ventilation]) and a continuous thoracic epidural infusion specifically placed for post-operative pain management (62318, Injection,including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic).

The Correct Coding Initiative (CCI) bundles 62318 into the anesthesia code. You can bypass the bundling edit to indicate that the epidural is separate and distinct from the general anesthetic mode of anesthesia.

Important: You should never use modifier 59 for E/M services, says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas. If you're reporting a separately identifiable E/M service with another procedure on the same day, you'll turn to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

If you are unsure whether two procedures are subject to bundling edits, check the CCI edits. The CCI edits list two codes as "mutually exclusive" of one another or pair them together as comprehensive and component ("bundles" them). If you see reference to "column 1" and "column 2" codes, CCI bundles the procedures and normally you would not report them together.

Unbundling is not automatic: Be aware, Kernaghan says, that you can't automatically override a CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient meeting.

Here's why: Before appending modifier 59, check the modifier indicator for the bundled code pair. You'll find the modifier indicator in Column F of the CCI Excel spreadsheet, which you can download from www.cms.hhs.gov/NationalCorrectCodInitEd.

A modifier indicator of "0" means that you may not unbundle the edit combination under any circumstances.

Alternately, a "1" indicator opens the possibility for you to override an edit using a modifier if you can verify that the procedures are distinct from one another.

Example: Your physician performs a greater occipital nerve injection (64405) and trigger point injection on two muscles (20552). The greater occipital nerve injection is performed for occipital neuralgia (723.8) and trigger points are injected in the left multifidus muscle at L5 (vertebral level) and left latissimus dorsi muscle at L1, both for myofascial pain (729.1). The 20552 code (column 2 code) is bundled into the 64405 (column 1 code). Since the injections were performed in different anatomic locations, you are clear to bypass the bundling edit by appending modifier 59 with the 20552 code.

How it works: Attach modifier 59 to the procedure code in column 2 (20552 in this example). If you break a CCI edit or bill for a separate procedure as outlined by the CPT, append 59 to the "separate procedure" code found in column 2.

Pitfall: For mutually exclusive code pairs, don't assume that the lower-paying code is the one to which you should attach modifier 59. In many mutually exclusive bundling edits, the code with the higher relative values is in column 2.

Although modifier 59 is on the OIG watch list, there is less risk of overusing it if it's well-supported, says Rena Hall, CPC, billing/insurance specialist of the Kansas City Neurosurgery Group in Missouri.

Important: Never use modifier 59 just to get paid for a procedure. "Make sure there is well-documented support for a separate and distinct procedure before adding modifier 59," Hall points out.

In addition, CPT instructions dictate that if a more specific modifier describes the situation, you should not use modifier 59. Because the modifier has the potential to bypass CCI edits, practices use this modifier too often, confirms Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of Surgery and Anesthesiology.

Modifier 59 "should be the modifier of last resort and only used when there is no other modifier to compliantly bypass the bundling edit and the procedure was clearly distinct and different from that of the other procedure. There are also other modifiers that could be considered before using the 59 (RT, LT, 58, 78, 79, etc.)," she adds.