Modifier 59 Made Easy:
Look for Separate Location/Session
Published on Sat Jan 06, 2007
Be sure to check CCI for a -1- modifier indicator -- or face denials Watch out: Payers know that modifier 59 is ripe for abuse, and time and again it comes under increased scrutiny from Medicare, the HHS Office of Inspector General (OIG) and others. Here are four expert-approved ways to bulletproof your modifier 59 (Distinct procedural service) claims.
1. Recognize When 59 Applies You may use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. Specifically, CPT -- backed by guidelines found in Chapter 1 of the national Correct Coding Initiative (CCI) -- instructs that you may append modifier 59 when your surgeon: sees a patient during a different session treats a different site or organ system makes a separate incision/excision tends to a different lesion treats a separate injury. Example: The surgeon performs a single lesion excision near the right wrist, along with lesion excision followed by adjacent tissue transfer at another location near the elbow.
In this case, you should report the lesion excision followed by adjacent tissue transfer near the elbow using the appropriate tissue transfer code only (for example, 14021, Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm). You may report the lesion excision in a separate location using the appropriate lesion excision code (for example, 11601, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.6 to 1.0 cm) with modifier 59 appended. Although CCI bundles lesion excisions (11400-11646) to adjacent tissue transfers (14000-14350), in this case the tissue transfer (near the elbow) and excision (near the wrist) are in separate locations. You may report both codes, but to indicate the excision's separate nature (and to override the CCI edit), you must append modifier 59 to 11601 and provide supporting documentation to justify the claim. Reminder: CPT indicates that you should not use modifier 59 if another, more specific modifier (such as modifier 58, Staged or related procedure or service by the same physician during the postoperative period) describes the situation better. In addition, you should never append modifier 59 to any E/M service code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach for the American Academy of Professional Coders, the coding organization in Salt Lake City.
2. Look to CCI for Bundles, Options If you have any doubt that two procedures are subject to bundling edits, simply check the CCI. If the CCI lists any two codes as -mutually exclusive- or pairs them together as -column 1- and -column 2- codes, you know the procedures are bundled, and you would not normally report them together. Note: All procedures [...]
