ED Coding and Reimbursement Alert

If you’ve ever been confused about when to separate bundles, here are the facts.

You’ve certainly heard that modifier 59 is supposed to only be used as the “modifier of last resort,” but how do you know when your ED is reporting it correctly? CMS has tried to make that determination a little simpler with a transmittal update. ED Coding and Billing Alert checked out the changes and picked out the most important facts – read on to find out the scoop.

Background: On December 28, CMS issued an update to Transmittal 4188, with an implementation date of January 30, 2019. As part of its clarification to the National Correct Coding Initiative (NCCI) section of the Medicare Claims Processing Manual, the transmittal spells out the requirements for when modifier 59 (Distinct procedural service) is appropriate. CMS has published such information elsewhere, but the agency has now taken the step of adding this verbiage to chapter 23 of the Manual.

A summary of the changes – along with ED-specific examples – are below.

Check These Examples of When You Can – And Can’t -- Use Modifier 59

Example 1: “Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ,” the transmittal states.

ED-Specific Scenario: A patient presents with a laceration of the proximal finger and a noncontiguous nail bed injury on the same finger. As these are two distinct injuries and not connected, then the 59 modifier would be appropriate to indicate separate noncontiguous procedures:

• 11760 (Repair of nail bed)
• 12001-59 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less)

Example 2: “Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day,” the transmittal says.

ED-Specific Scenario: A patient presents to the ED in the morning for a nosebleed and sees Dr. Smith, who uses simple packing to stop the bleeding. That afternoon during a softball game, the patient is hit in the face with a baseball glove and his nose begins to bleed. The second nosebleed is more severe, and when the patient comes to the ED, Dr. Smith must use extensive cautery to stop the bleeding. The modifier 59 would be used on the procedure since the visits were for separate encounters on the same date:

• 30901-59 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method)
• 30903 (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method)

Example 3: “Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different,” the transmittal says.

ED Specific Scenario: A patient presents with two abscesses on her right forearm. The ED provider performs a simple incision and draining (I&D) on the first abscess and then performs a complex I&D on the second abscess. The physician report the following codes

• 10060-59 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single)
• 10061 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; complicated or multiple)

In this case, you cannot append modifier 59 to 10060 -- in fact, you cannot report 10060 at all, even though the descriptors are different on the two codes. The reality is that if you perform a more extensive procedure, you should only report that. Here, 10061 is the more extensive procedure, so in this situation, that is the only code you should bill.

Example 4: “Modifier 59 is used appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure,” the transmittal notes.

Modifier 59 Isn’t Automatically the Best Choice

Although CMS has clarified its regulations for when you can report modifier 59 (Distinct procedural service), that doesn’t mean you always should append it when reporting codes together that are typically bundled under the Correct Coding Initiative.

In some cases, other modifiers may be more appropriate, and in those situations, you should report these modifiers instead of 59. Alternative modifiers may include the following, among others, depending on the circumstances:

• Modifier XE -- Separate encounter
• Modifier XS -- Separate structure
• Modifier XP -- Separate practitioner
• Modifier XU -- Unusual Non-Overlapping Service
• Modifier 25 -- Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure orother service
• Modifier LT-- Left side
• Modifier RT-- Right side
• Modifier 57 -- Decision for surgery  

ED-Specific Scenario: An ED physician suspects laryngeal edema in a burn patient and performs flexible nasal fiberoptic laryngoscopy. Moderate edema is noted, which subsequently worsens, ultimately requiring intubation. You could report:

• 31575-59 (Laryngoscopy, flexible; diagnostic)
• 31500 (Intubation, endotracheal, emergency procedure)

Keep in mind: In all of the above examples, the transmittal states, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59.”

Therefore, you need not document different diagnosis codes to justify the use of modifier 59 – and you shouldn’t assume you can separate NCCI edits just because you have separate ICD-10 codes.

Resource: To read CMS Transmittal 4188, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf.

To read CMS’ Modifier 59 Article, visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf.