Gastroenterology Coding Alert

Question: When we're following Correct Coding Initiative (CCI) edits, which code should we apply modifier 59 to? My gastroenterologist performed a procedure on two separate sites and should receive reimbursement for both. Should it be the code with the lower relative value units (RVUs)?

New Jersey Subscriber

Answer: Making sure you know which code you are attaching modifier 59 (Distinct procedural service) to could mean valuable additional reimbursement. You should always place the modifier on the code that will be denied due to CCI edits. This code is the column 2 code or the component code.

- If you're stuck on whether you should bill codes with modifier 59, check the CCI edits. If the codes you report have indicators of "1" next to them, you may be able to append an appropriate modifier to bypass the edit. If the code has a "0" indicator, you cannot bypass the edit. The CCI edits change quarterly, so be sure to keep abreast of all updates.

- Time saver: Increase your modifier 59 reimbursement rate by using it only when absolutely necessary -- many payers do not require the use of a modifier in multiple-procedure scenarios. Check with your individual payer to see if modifier 59 is necessary when reporting multiple-procedure claims.

- On the other hand, don't be afraid to use modifier 59 if you have no recourse -- just make sure it is "the modifier of last resort."

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.