General Surgery Coding Alert

The use of modifier -59 (distinct procedural service) can be a double-edged sword for general surgery practices.

Typically, -59 is used to identify procedures performed on the same day that normally would not be reported together because they are bundled in a global package. Under certain circumstances, however, general surgeons may use modifier -59 to indicate that a procedure was distinct or independent from other services performed during the same 24-hour period.

According to CPT 1999, This may represent a different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

However, when another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used.

The effect of adding the -59 modifier to the secondary procedure is to unbundle the two procedures in the global period, overriding the automatic edits of private payers and Medicares Correct Coding Initiative edits.

Use Modifier -59 Cautiously

Because of its unbundling capability use of the -59 also can be a red flag for medical review; if used incorrectly, it could lead to an audit or worse. Furthermore, improper use of this modifier indirectly penalizes those practices that utilize it correctly, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ, which does general surgery reimbursement.

Unfortunately, many general surgeons use the -59 to obtain reimbursement for procedures that should not be unbundled. For example, some general surgery coders bill 49000 (exploratory laparotomy, exploratory celiotomy with or without biopsy[s][separate procedure]) with the -59 modifier attached when the laparotomy was performed to allow access for the primary procedure.

In effect, using the -59 in this scenario tells payers that the surgeon performed the exploratory laparotomy and then later the same day, an appendectomy or colectomy was performed, when in fact both procedures occurred during the same session.

In the short term, the misuse of -59 may result in payment; however, should you be audited later, there would likely be adverse consequences for the practice.

Use For Different Times or Different Sites

Some procedures performed at different times on the same day may be billed with modifier -59. For example, a surgeon may perform a 36533 (insertion of implantable venous access port, with or without subcutaneous reservoir) in order to administer medication to a patient over the long term. But later the same day, the patients condition deteriorates and the surgeon has to insert a central line that requires a cutdown because the patients veins are too weak to withstand the insertion of the catheter (36491, placement of central venous catheter [subclavian, jugular or other vein] [e.g., for central venous pressure, hyperalimentation, hemodyalysis, or chemotherapy]; cutdown, over age 2). In this situation, both the 36533 and the 36491 should be billed, with modifier -59 attached to the second procedure.

Note: See story on insertion of venous catheter on page 17.

Procedures performed at different sites also may appropriately use modifier -59. One scenario involves vein stripping. A surgeon does an excision of the greater saphenous vein on the left side (37720, ligation and division and complete stripping of long or short saphenous veins), and an excision of secondary clusters on the lesser saphenous vein (37785, ligation, division, and/or excision of recurrent or secondary varicose veins [clusters], one leg).

The 37785 would need a -59 to indicate it was separate from the greater saphenous vein, that it was a separate site on the vein, because 37720 and 37785 are normally bundled together.

Modifier -59 also may be used, in some cases, to bill for excision of lesions, says Terri Odom, CPC, a practice coder with HealthFirst Medical Group, a multispecialty group of about 150 physicians, including 10 general surgeons, in Portland, OR.

For example, the patient has a 1.5 cm malignant lesion on an arm, and a 2.2 cm lesion on his or her leg. The excision on the leg would be coded 11603 (excision, malignant lesion, trunk, arms or legs; lesion diameter 2.1 to 3.0 cm), while the smaller lesion on the arm would be coded 11602 (lesion diameter 1.1 to 2.0 cm).

Both Odom and Cobuzzi say that when they have billed these with a modifier -59 attached, they are reimbursed. On the other hand, when modifier -51 (multiple procedures) is used, the claims are routinely denied because it appears to the payer that unbundling has taken place.

Note: Modifier -59 would not be appropriate when using, for example, codes 11602 and 11623 (excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0) because the CPT definitions already indicate the lesions were on separate sites.

If the lesions were on related sites but were separate, using modifier -59 would also be correct. For instance, if the surgeon removes three benign lesions from a patients right arm, he or she would code all three procedures 11401 (excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs, lesion diameter 0.6 to 1.0 cm). And because the surgeon cant use -RT or -LT modifiers because all three lesions were on the same arm, modifier -59 would be attached to the second and third 11401 billed to indicate all sites were separate on the patients arm.

Note: When billing for procedures involving separate fingers or toes, neither modifiers -59 nor -51 apply. Instead, the surgeon would use the -F and -T modifiers (FA-F9, beginning with FA for the left thumb; TA-T9, starting with TA for left great toe) to indicate which fingers or toes were worked on. For example, if a patient had three toes amputated (28820, amputation, toe; metatarsophalangeal joint), the 28820 would be billed three times, with the appropriate toes listed as follows: 28820-T1; 28820-T2;
28820-T6.

Odom adds that even when modifier -59 is used correctly to indicate that a bundled procedure was done at a different time during the same day or on a different site, surgeons should expect a reduction in the reimbursement for the second procedure.

When determining whether modifier -59 should be used, you need to ask the following questions if the procedures in question were bundled:

1. Is there a separate operative note that indicates the procedures took place at different times during the day?

2. Were the procedures performed on different sites of the body, or was one procedure performed just to provide access for, or to facilitate, the primary procedure?
If the procedures took place at different times, or if the procedures were performed on different sites of the body, modifier -59 may be appropriate.

If, on the other hand, the secondary procedure was performed simply to facilitate the primary procedure, you should not use modifier -59.

Dont Use Time As Factor

It is important to remember that the amount of time spent on a procedure does not, in itself, permit the use of the -59 modifier.

For example, in the course of performing a partial colectomy, lysis of adhesions (44005, enterolysis [freeing of intestinal adhesion][separate procedure]) is typically performed. As a separate procedure, the lysis of the adhesions is automatically bundled into the partial colectomy.

Sometimes, however, the lysis can be complicated and take significantly longer to perform, and some practices will code the 44005 with a -59 modifier attached in order to bill for the extra time spent on the lysis.

This is not the appropriate way to get reimbursed for a longer-than-expected lysis. Instead, modifier -22 (unusual procedural services) should be used. Using -22, with an operative note that describes the inordinate amount of time spent on the lysis, will let the carrier know that something out of the ordinary happened during a procedure that warrants extra reimbursement.

Cobuzzi adds that many payers, including Medicare, are bundling some procedures strangely. Commercial carriers, for their part, may arbitrarily decide to change or apply Medicare guidelines. And some practices have responded to such repeated irrational bundling by looking for other ways to get reimbursed for the procedures they perform.

Note: Contacting the carriers medical director can be helpful, but Cobuzzi says getting through can be near-impossible.

If a carrier rejects a claim because procedures were kept bundled and instructs you to use modifier -59, it would be helpful to get that instruction in writing; otherwise, if the claims are later audited, the practice could be accused of fraud. Unfortunately, Cobuzzi says, there is little chance such written instructions will be forthcoming.