Shore up diagnostic test, modifier -59 claims in 2004 What could be more frustrating than coding a magnetic resonance imaging (MRI) or other diagnostic test perfectly, only to have your claim denied? That's what could happen if a physician who is excluded from the Medicare program ordered the diagnostic test in the first place. But you can prevent this problem by ensuring that all your surgeons are properly credentialed.
If your surgery practice owns its own testing equipment, the U.S. Office of Inspector General (OIG), as outlined in its 2004 Work Plan, will be checking to be sure that the physicians ordering tests are not excluded from Federal healthcare programs. To avoid denied claims, you should check the OIG's database of excluded physicians to be sure that none of your ordering physicians are listed. You can either download the entire database, or search it using physician names or business names, at
http://oig.hhs.gov/fraud/exclusions.html. Apply Modifier -59 With Caution The OIG also intends to "determine whether claims were paid appropriately when modifiers were used to bypass National Correct Coding Initiative (NCCI) edits." Although several modifiers - including -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period) - can separate bundled NCCI edits, surgeons usually use modifier -59 (Distinct procedural service) to report two separate (but usually bundled) services provided on the same day, says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif.
For example, a surgeon treats a child with multiple leg wounds who has fallen from a playground swing. She performs intermediate repair and closure for several wounds on the child's right leg, totaling 12 cm, and performs two simple repairs on the left leg, totaling 8 cm. You would report the intermediate repairs with 12034 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm), and the simple repairs as 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).
Because the descriptor for wound care codes specifies only general anatomic locations (for example, "trunk and/or extremities"), payers cannot easily discern that the intermediate and simple repairs occurred at different sites. As a result, many payers will bundle the simple repair to the intermediate repair of the same anatomic location, says Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Company, an Atlanta-based medical management consulting firm. Appending modifier -59 to 12004 specifies that the simple repairs occurred at a different site and, therefore, are distinct [...]
