Cardiology Coding Alert

If you're still treating modifier 59 as a catchall, especially after CPT 2008 clarified its use, you could be attracting unwanted regulatory attention.

Watch out: "Modifier 59 (Distinct procedural service) is the Prednisone of modifiers," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. It can be of great help, but it can be very dangerous at the same time.

Keep your modifier 59 use on the up-and-up by following these updated guidelines.

Consultants previously stressed that you should restrict your modifier 59 use to certain circumstances. CPT 2008 now makes that guidance clear. The modifier's revised descriptor in Appendix A now specifies that "Documentation must support:

• different session

• different procedure or surgery

• different site or organ system

• separate incision or excision

• separate lesion

• separate injury (or area of injury in extensive injuries)."

Some coding consultants previously suggested that the above scenarios in Appendix A were merely examples, not qualifying circumstances. They pointed to the modifier's description of circumstances that "may represent a different session ..." as evidence. The change to "Documentation must support ..." closes this loophole.

"I have always felt modifier 59's use was limited to those examples," Cobuzzi says. "The 2008 CPT guidelines make the modifier's guidelines more crystal-clear."

Simplified: The six examples boil down to "the two issues of different sites or operative sessions," Cobuzzi says. Ask, "Does the provider perform the two normally bundled procedures at different anatomical sites or operative sessions?" If the codes you report on the claim don't meet this critical criteria, modifier 59 does not apply, and you should not use it.

Learn From a Modifier 59 Example

Here's an example that meets modifier 59's different- site criteria. If your cardiologist catheterizes the left and right common carotid arteries, you will report 36216 (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family) for the right common carotid (RCC) and 36215 (Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch, within a vascular family) for the left common carotid (LCC). If you don't put modifier 59 on 36215, your payers will assume that both codes apply to the same vascular family.

Before using modifier 59, remember it is the modifier of last resort. "As described for modifier 59 without revision, precaution is given to not use modifier 59 when another already established modifier is appropriate, unless no more descriptive modifier is available, and so long as it best explains the circumstances," says Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio.

Example: A cardiologist performs interventions in multiple coronary arteries. Although the procedures occur on separate sites, you would not use modifier 59. More appropriate modifiers describe the circumstances -- modifiers LC (Left circumflex), LD (Left anterior descending), and RC (Right coronary).

CPT instructions limit you to reporting one intervention in each of the three recognized coronary arteries. However, the Correct Coding Initiative (CCI) bundles every possible combination of coronary intervention codes (92980, 92981, 92982, 92984, 92995, and 92996).

Therefore, when your cardiologist performs more than one of these interventional codes and you report this on the claim form for the same patient and the same date of service, you'll need a CCI-recognized modifier. Otherwise, your payer will deny the lesser of the two interventional codes.

While CCI recognizes modifier 59, modifiers LC, LD, and RC are more specific. They label each intervention as being performed in the left circumflex, left anterior descending, and right coronary arterial system respectively.