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Understanding Modifier -59 Can Make or Break Claims

Published on Wed Jul 07, 2004

Know when same-day services qualify as 'separate'

Anesthesia providers often perform more than one service for patients on the same day, which means modifier -59 (Distinct procedural service) often applies to your claims. Take the time to understand its nuances, and you'll be rewarded with accurate claims and sufficient reimbursement.

Check the Times of Multiple Sessions

When you append modifier -59, you indicate to the carrier that the anesthesiologist performed more than one service for the patient. But the services you report with modifier -59 must qualify as "distinct" from each other instead of being services that normally go together. The physician might perform these services during separate sessions or might perform multiple services during the same session that are unrelated.

Note: For tips on distinguishing modifier -59 from modifier -51 (Multiple procedures), see "Make Modifier -51 Your Friend".

"The descriptor's use of the word 'distinct' is what seems significant here," says Lori Mehlbauer, an anesthesia coder in Louisville, Ky. You must be able to show that the services were separate from each other before reporting modifier -59.

Mehlbauer and Joseph T. Fisher, CPC, with Healthcare Administrative Partners LLC, in Media, Pa., offer three common scenarios using modifier -59 with anesthesia or pain management services:

  • Placement of an epidural catheter for postoperative pain relief. The physician might place the epidural catheter just prior to surgery or following the case. These scenarios count as "different sessions" and qualify for modifier -59 because the epidural placement is not part of the procedure's anesthesia and is not included in the global anesthesia fee. Report CPT 62319 (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; lumbar, sacral [caudal]) and append modifier -59.
  • Anesthesia care when a patient returns to the operating room (OR) the same day. Reporting modifier -59 for cases when a patient returns to the OR is appropriate for the anesthesiologist, but you'll rarely report modifier -78 (Return to the operating room for a related procedure during the postoperative period). Surgeons primarily use modifier -78.
  • Nerve blocks with other services. Include modifier -59 when you code a nerve block (644xx series) for postoperative pain relief. Pain management practitioners also use modifier -59 to report multiple services such as a nerve block (644xx) or joint injection with a trigger point injection of a completely different area. For example, code a large-joint injection during the same session as a trigger point of the elbow with 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) and 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). Append modifier -59 to 20552 as the second service.

    Include These Elements in Your Documentation

    Remember: Having sufficient documentation to show that the provider performed two distinct services is key when you report modifier -59.

    "This is especially true when a patient receives general anesthesia and then a block is administered for post-op pain," Mehlbauer says. She says carriers often ask for records to confirm the separate services, so the anesthesia record needs to show clearly that the general anesthesia and the block placement were separate.

    "We tell our clinical staff to write 'for post-op pain' when they're noting the block in the patient record, and to make sure the general anesthesia is properly noted," she says. "Failure to do this has resulted in loss of payment for these services."

    You might want to ask your physicians to document things even more clearly. Fisher's group asks their doctors to note, "Epidural catheter placed for post-op pain, not mode of anesthesia." And because postoperative pain relief generally is included in the surgeon's service, he also suggests obtaining a written request when the surgeon wants the anesthesiologist to provide this service.

    Watch for - and Fix - Incorrect Bundling

    Mehlbauer's biggest problems when reporting modifier -59 are claims processors'inexperience and payment systems' failure to recognize correct use of this modifier. Other coders say their biggest problem is working with carriers that treat modifier -59 like modifier -51 and reduce their payment for the second service by 50 percent.

    "Sometimes the carrier's software automatically bundles invasive monitoring lines with the anesthesia service even though they should be separately billable," adds Tonia Raley, CPC, claims manager with Medical Information Systems in Phoenix. "If their staff can't manually override the system, you might need to always include modifier -59 to keep the bundling from happening and get the correct reimbursement."

    Raley also cautions against reporting modifier -59 too often. "This is known as the 'unbundling' modifier, and using it consistently might throw up flags to your carrier," she says. "Try to report it only when another modifier doesn't fit the situation."

    Trick of the trade: Whatever your challenge may be, talk with your representative to straighten out modifier problems. "We can usually resolve a matter on the phone and by faxing or sending the records to the carrier," Mehlbauer says. "While it is a nuisance and takes my staff's time, we really don't have a lot of trouble with modifiers once we explain things."

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