ED Coding and Reimbursement Alert

Modifier -59 is for procedures that are not reported together in most cases

When a physician performs multiple procedures in a single visit -- a common occurrence in an emergency department -- you'll likely use either modifier -51 or modifier -59 to prove that you aren't trying to double-dip on your claim.

Keeping the rules straight on both of these modifiers can be hard, especially on an especially hectic day in the ED. We'll take a closer look at these modifiers, along with some expert tips to keep in mind when you report them on your claims.

Separate Related Codes With Modifier -59

Modifier -59 (Distinct procedural service) identifies a procedure that is distinctly separate from any other procedure or service the physician provides on the same date. Use modifier -59 only when no more descriptive modifier is appropriate (that is, an anatomic modifier or a staged-procedure modifier). 

Different session or patient encounter, different site or organ system, or separate injury are key elements suggesting the use of modifier -59 in the ED, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.

Example: A patient reports to the ED after falling down stairs and cutting his right hand in several places on a broken windowpane. The physician closes a 1.5-centimeter laceration on the right second finger, as well as a 6-centimeter multilayered laceration of the right palm.

On your claim, report 12042 (Layer closer of wounds of neck, hands, feet, and/or external genitalia; 2.6 cm to 7.5 cm) followed by 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.5 cm or less). Also, append modifier -59 to 12001.

If you don't use modifier -59 on the above example, "you will most likely receive a denial from the insurance company stating that 12001 is bundled in the more extensive procedure [12042]," says Sandra Pinckney, CPC, coding supervisor at Certified Emergency Medicine Specialists in Grand Rapids, Mich.

The modifier lets the insurance company know that although the codes are related to each other, the doctor performed the procedures on distinctly different areas and they can be reimbursed separately. Modifier   -59 is important in any ED, Pinckney says, "and there are emergency departments, particularly those with trauma units, who might have to use this modifier several times a day."

"Knowing modifier -59 will save a lot of time in appealing denials for perfectly legitimate procedures that will be paid as soon as the insurance company understands that you aren't unbundling procedures; they are distinctly separate from each other," Pinckney says.

Protection: Want to increase your chances of coding success with modifier -59? Talk to your doctors, because your modifier -59 claims will go through a lot easier with good operative notes.

"As far as documentation requirements go, I don't see it as that much of an issue as long as your physician is giving an informative procedure note," Pinckney says.

Use Modifier -51 for Multiple Surgeries

When your physician treats a patient with multiple injuries requiring multiple surgeries, you should include modifier -51 (Multiple procedures) on your claim to show that the surgeries were indeed separate.

Modifier -51 is "an informational-type modifier ... for use on the second, third, etc., surgical procedure performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources.

Example: A patient reports to the ED with a pair of cuts on her right forearm. The physician sutures a 2.2-centimeter simple wound on the forearm and makes a separate, complex 2.1-centimeter closure a few inches away on the same forearm.

Report 13120 (Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm) first, followed by 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), with modifier -51 attached to 12001.

The modifier is appropriate because the procedures are close enough to cleanse, prep, and anesthetize in the same session, but were clearly separate closures.

Modifier -51 shows the insurance company that "the procedures performed were unrelated to each other, even though the injuries both occurred at the same time in the same accident," Pinckney says.

Code Order Is Crucial

Remember: When filing claims with modifier -51, make sure you report the code with the highest relative value units (RVU) first; the first code listed on the claim is the only code that will be reimbursed at 100 percent. Modifier -51 "prevents the insurance company from changing the order of your codes, because the most expensive procedure should be listed first," Riesser says.

Payoff: In the above example, the RVU for 13120 is 5.40 for facilities and 7.19 for nonfacilities, while 12001's RVU is 2.35 for facilities and 3.86 for nonfacilities -- so make sure you pay attention to sequence when filing claims with modifier -51.