General Surgery Coding Alert

59 really isn’t you’re only ‘bypass’ option.

You’re so used to using modifier 59 (Distinct procedural service) when circumstances allow you to override a Correct Coding Initiative Edit that you might not know you have other options.

In fact, CMS instruction has always indicated that you should use a more specific modifier, if available, but most coders didn’t really know what those were.

Now is a great time for a refresher, because CMS recently added to the list of applicable modifiers by introducing four more modifiers that Medicare contactors will accept to bypass CCI edits.

Re-examine CCI Override Rules

When CCI lists a code pair as either a mutually exclusive or comprehensive/component edit, the general rule is that you should not report both codes together. However, CCI lists a "modifier indicator" of "0" or "1" to let you know if you can ever break the bundle rule, as follows:

"0" indicates that it is never acceptable to bill these procedures together

"1" indicates that codes in the edit pair are bundled, but can be billed separately under certain circumstances, such as a separate site, separate incision, separate patient encounter, or separate injury.

Most coders who are trying to separate CCI edits will use either 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 or other service) for edits involving E/M codes, or modifier 59) for bundles that involve two procedures. However, coding experts have long maintained that modifier 59 should be the modifier "of last resort," making many coders reluctant to use it extensively.

Look at CMS’s New Modifier List

CMS Transmittal 1136 announces that, as of Jan. 1, 2013,you can use the following modifiers to override a CCI edit with a modifier indicator of "1":

24 -- Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period

57 -- Decision for surgery

LM -- Left main coronary artery

RI -- Ramus intermedius

"This is good news because the main modifier used to bypass CCI edits was 59," says Laureen Jandroep, CPC, CPC-I, CMSCS, CHCI, senior instructor at CodingCertification.org in Oceanville, NJ. "Now it will be more granular."

Whereas modifiers LM and RI will mainly be used by heart surgeons, the other two modifiers are quite familiar to most other coders.

You can append both modifiers 24 and 57 to E/M codes when the E/M service is either unrelated to a surgery (modifier 24) or results in the decision to perform the bundled procedure (modifier 57).

Modifier 24: You should only append modifier 24 to an appropriate E/M code when an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure, says Ruth Borrero, CUC, billing supervisor at Prohealth Care in Lake Success, N.Y.

Modifier 24 tells the payer that the provider is seeing the patient for a new problem. "The diagnosis code tells the story but payers want to have coders put the modifier on the claim to indicate this -- perhaps because of the way their edits/flag system is set up," Jandroep says.

When you report modifier 24, the E/M service must meet these criteria:

The E/M service occurs during the postoperative period of another procedure

The current E/M service is unrelated to the previous procedure

The same physician (or tax ID) who performed the previous procedure provides the E/M.

Modifier 57: You might use modifier 57 when your surgeon performs a procedure and a distinct E/M service for the same patient on the same day. "Modifier 57 is added to an E/M code when the decision for a major surgery with a 90-day global period is made," Borrero explains.

"Modifier 57 tells the story that even though there is an E/M and a surgery procedure on this claim form within a day of each other, the E/M is not a pre-op visit," Jandroep agrees. "It was the ‘decision for surgery’ visit and is therefore not bundled into the surgery code (package)."

Use modifier 57 if the claim meets all of the following criteria:

The E/M service directly prompted the surgeon’s decision to perform surgery

The surgical procedure following the E/M has a 90-day global period

The same surgeon (or another surgeon with the same tax ID) provided the E/M service and the surgical procedure.

Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would expect to see the same diagnosis code for both the E/M and the surgical procedure. The surgeon would not make a decision for surgery based on a significant problem unrelated to the procedure.

Resource: To read the complete Transmittal, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1136OTN.pdf.