Cardiology Coding Alert

Be sure your documentation supports separating services

Adding modifier -59 to a National Correct Coding Initiative (NCCI) cardiology procedure edit with a status indicator of "1" may be an easy fix to receive separate reimbursement, but you could be attracting regulatory attention. The best advice is to make sure you have the necessary documentation.

Treating -59 as a Catchall Is a Pitfall

Don't fall into the trap of using modifier -59 (Distinct procedural service) if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant. You should be using modifier -59 only as a last resort.
 
Example 1: A cardiologist removes a pulse generator (33233, Removal of permanent pacemaker pulse generator) and implants a single pacemaker (33207, Insertion or replacement of permanent pacemaker with transvenous electrode[s]; ventricular).
 
You shouldn't apply modifier -59, however. NCCI doesn't bundle 33233 and 33207, and you can achieve separate payment simply by appending modifier -51 (Multiple procedures) to 33233. And even this may not be necessary for many payers. Many Medicare carriers and others have said that you no longer need to attach modifier -51. 
 
Example 2: A cardiologist performs a diagnostic cardiac catheterization that results in a stent placement on the same day.
 
In this case, you should append modifier -59 to both supervision and interpretation codes 93555 (Imaging supervision, interpretation and report for injection procedure[s] during cardiac catheterization; ventricular and/or atrial angiography) and 93556 (... pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits [whether native or used in bypass]), says Sarah Tupper, a coding specialist for Central New York Cardiology in Utica. "Using modifier -59 with those codes shows that those codes pertain to the cath, not the intervention," she says.
 
Don't Unbundle Without Cause

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.
 
"[Modifier -59] is overused just to get through the edits," says Annette Grady, CPC, CPC-H, a consultant with Eide Bailly in Bismark, N.D. Coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
But Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation to back it up.
 
For example: A cardiologist performs a nonselective catheter placement (such as a unilateral lower-extremity study through the sheath) and also performs a selective catheterization (such as a contralateral lower-extremity study.)  Now you're left with the decision - should you report 36140 separately in addition to the appropriate catheter placement code (36245-36247) or not?
 
When you should unbundle: You can use modifier   -59 in two situations.
 
Situation A: If the cardiologist performs a nonselective catheterization and a selective catheterization through two separate catheters introduced into two separate arteries, you can append modifier -59 to 36140 (Introduction of needle or intracatheter; extremity artery).
 
Situation B: If the cardiologist performs the nonselective catheterization and selective catheterization at two separate patient encounters on the same date of service, you are justified in reporting the appropriate selective catheter placement code (36245-36247) and 36140-59.
 
When you shouldn't unbundle: If the cardiologist performs a procedure along the path of a selective catheterization, you should not report the nonselective catheterization separately. The cardiologist passes the catheter through the vessel in order to perform the selective catheterization.

Be Confident Beneath CMS' Spotlight

CMS is now looking closely at -59, Grady believes. While each carrier and payer has different claims-review software, you may safely assume that many carriers will single out claims with modifier -59 for extra scrutiny.
 
The North Dakota Medicaid program actually handles all claims with modifier -59 by hand, Grady adds. "It automatically pops them out," and reviewers go over the claims for medical necessity.