Cardiology Coding Alert

Don't risk unwanted payer scrutiny

When you add modifier -59 (Distinct procedural service) to a code, you may successfully override a National Correct Coding Initiative bundle. But beware: Appending modifier -59 could trigger carrier audits and requests for refunds.
 
"It is a very dangerous modifier because a lot of times people think of it as a license to unbundle," says Barbara Cobuzzi, MBA, CPC, ChBME, president of Cash Flow Solutions in Lakewood, N.J. "If you disagree with a bundle that is part of NCCI, using -59 because you're mad about the bundle isn't appropriate."
 
To test whether you're using modifier -59 appropriately, ask yourself the following questions:
 1. Does the component second procedure represent a separate site of surgery?
 2. Did the component separate procedure occur during a separate session?
 3. Does the physician documentation support -59?

If you answer "yes" to each of these questions, you're probably safe to append modifier -59. If not, think long and hard before putting that -59 on your claim.
 
Much of the modifier -59 confusion might come from the modifier indicators in NCCI, says consultant Cindy Parman, CPC, CPC-H, with Coding Strategies Inc. in Atlanta. If the status indicator is "0," that means the modifier will not bypass the bundling edit, and a "1" means the modifier is allowed and will bypass the edit, she says.
 
Lesson: That doesn't mean, however, that if the indicator is 1, you should use the modifier, Parman says. "When a code combination lists indicator 1, it means that if the documentation supports a separately identifiable service [and the clinical circumstances meet the above criteria] ... then it is appropriate to apply modifier -59." But if the physician performs both services in the same session and one service "is integral to the other," you absolutely should not use modifier -59.
 
For instance, CMS considers temporary pacemaker placement (33210) to be part of a coronary angioplasty procedure (92982) and will not pay for both when the physician performs them together, according to the American College of Cardiology's (ACC) Guide to CPT 2003. 
 
Think of modifier -59 as the "modifier of last resort," Parman tells coders. And don't overlook the other modifiers that will also bypass the NCCI edits. 
 
For instance, NCCI version 9.2 (effective July 1) indicates that you can use the HCPCS Level II coronary modifiers -RC (Right coronary artery), -LD (Left anterior descending coronary artery) and -LC (Left circumflex, coronary artery) to unbundle multiple intervention edits.
 
For more details and a list of NCCI-related modifiers, refer to http://www.cms.hhs.gov/medlearn/ncci.asp.