Gastroenterology Coding Alert

Save your claim departments time with theis advice

If you're still treating modifier 59 as a catchall, you could be attracting unwanted regulatory attention. Kick these three myths and maximize your modifier 59 (Distinct procedural service) use as well as your reimbursement.

Myth 1: Treat Modifier 59 as a Safety Net

Don't fall into the trap of using modifier 59 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 use modifier 59 only as a last resort.

Bottom line: Append modifier 59 to a claim only if you are certain of the distinct nature of the procedures you are reporting, and never simply to override Correct Coding Initiative (CCI) bundles and get paid.

"Modifier 59 is overused just to get through the edits," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network and executive officer on the AAPC's National Advisory Board.

Coders often turn to modifier 59 because "it unbundles nicely," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, coding analyst with CodeRyte Inc. in Bethesda, Md.

But Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation to back it up.

Myth 2: If Other Modifiers Work, Still Rely on 59

Not true. You should use modifier 59 when no other modifier applies to services performed by the same physician on the same day. This modifier specifically indicates that a procedure that your payer would normally bundle with other procedures was distinct during this surgical session. 

Be smart: Each time you are unsure whether a carrier accepts modifier 59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification, experts say. Then, chart each carrier's policies on 59 so you know whether to use it the next time you file a claim.

Making these phone calls may take a little time initially, but once you get a chart with each insurance company's policy on modifier 59, your claims department will be streamlined dramatically.

Myth 3: Only Use 59 on 'Separate Procedure' Codes

Although you'll primarily use modifier 59 with codes that CPT designates as "separate procedure," you may still use it in other circumstances as well.

For instance, you may also use modifier 59 with the primary procedure if that procedure has the higher relative value unit (RVU). CPT states that this modifier is "appropriate under certain circumstances." They include:

1. A different session or patient encounter. This means the gastroenterologist provides a distinct service during a different patient encounter--even though she may perform a similar procedure.

For example, your gastroenterologist performs procedures during the morning at an ambulatory surgery center and sees one patient with a colon polyp he removes with snare polypectomy. You would normally bill 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for that service.

However, later that day the patient returns to the hospital with repetitive vomiting and hematemesis. The gastroenterologist evaluates the patient and performs an esophagogastroduodenoscopy (EGD). Payers will subject the additional evaluation service and procedure to multiple-procedure rules if you don't apply modifiers.

Include your E/M code (99201-99205 for new patients or 99211-99215 for established patients) with modifier 25 and 43235 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) with modifier 59.

2. A different procedure or surgery. For example, your gastroenterologist performs an upper gastrointestinal endoscopy (EGD) with balloon dilation of the esophageal stricture and an EGD with biopsy of a gastric ulcer.

You should report 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter]) and attach modifier 59 to 43239 (... with biopsy, single or multiple). The modifier shows the carrier that the gastroenterologist performed two different procedures, even though they were both EGDs. Result: Payers will reimburse 43249 fully and reduce the reimbursement for 43239.

3. A different anatomic site or organ system. Your gastroenterologist performs a colonoscopy with a cold biopsy and removes a separate polyp by snare technique. You should report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) and attach 59 to 45380 (... with biopsy, single or multiple). The modifier shows the carrier that the physician treated two different sites.