General Surgery Coding Alert

Brush up on CMS guidance.

Before you use modifier 59 (Distinct procedural service) again, read this. Misuse and overuse of this modifier could result in claims denials, sacrificed pay, penalties, or worse.

Follow these expert tips to get the pay you deserve and avoid claims problems for your general surgery practice.

Tip 1: Track CMS Guidelines

You may use modifier 59 when you can document circumstances that result in the surgeon performing multiple procedures that don’t usually occur together.

CMS puts it this way in the Medicare Claims Processing Manual Chapter 23, (updated in Transmittal 4188 dated December 28, 2018):

• Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.
• Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day.
• Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different.

The manual goes on to document limited circumstances that warrant modifier-59 use for timed procedures or diagnostic and therapeutic procedures performed on the same day.

Resource: You can read the entire the transmittal at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf.

Tip 2: Acknowledge Other Suitable Modifiers

Modifier 59 isn’t the only modifier you can — or should — use to override an edit pair. CMS provides multiple CCI-associated modifiers that might do the job and be more appropriate and specific than 59. Alternative modifiers may include the following, among others, depending on the circumstances:

The X factor: The X{ESPU} modifiers describe the specific circumstance that justifies overriding an edit pair:

• XE (Separate Encounter)
• XS (Separate Structure)
• XP (Separate Practitioner)
• XU (Unusual Non-Overlapping Service).

Although CMS officially accepts these modifiers, you should ensure that your Medicare Administrative Contractor (MAC) processes claims using them before you report them.

Surgeons might also use anatomic modifiers to override the edit, such as LT (Left side) and RT (Right side) to distinguish procedures on different sites.

Coder tip: If you’re overriding an edit pair that includes an E/M code, you should never use one of the preceding modifiers. Instead, you should turn to 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) or 57 (Decision for surgery).

Tip 3: See CCI Impact on Modifier 59 Choice

The Correct Coding Initiative (CCI) publishes a list of procedure to procedure (PTP) edits consisting of two codes that a physician would not reasonably perform together based on the code definitions or anatomic considerations. CCI presents each code pair as column 1 and column 2 codes.

Caveat: CMS may allow you to report both codes of a PTP edit pair together if you can document one of those mitigating circumstances, such as different session or anatomic site. To alert you of this possible exception to an edit pair, CCI lists a modifier indicator of “1,” which means that you can report the two codes together under those appropriate, documented circumstances.

You should not use modifier 59 and other CCI-associated modifiers to bypass a CCI edit unless you’ve met the proper criteria for modifier 59 use, cautions Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Documentation in the medical record must satisfy the criteria required by any CCI-associated modifier,” she says.

For instance: You can use modifier 59 when the surgeon performs the bundled procedures for different anatomic sites/regions, different organs, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ, Falbo explains.

Caution: You should never append modifier 59 if the CCI modifier indicator for a PTP pair is “0.”

Note column change: CMS currently limits modifier use to the column 2 code of an edit pair. Effective July 1, 2019, CMS will allow you to place the modifier on the column 1 or 2 code of an edit pair to override a PTP bundle.

Resource: You can read Transmittal 2259 dated Feb. 15, 2019 that announced the change at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019-Transmittals-Items/R2259OTN.html.

Check Out This Coding Example

The op note indicates that the surgeon performed a 15 sq cm subcutaneous debridement on a patient’s left shin, and an 18 sq cm debridement to the muscle on a patient’s left thigh. In this scenario, you should report 11043 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) for the thigh debridement, along with 11042 (Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less) for the shin debridement.

Although CCI edits lists 11042 as a column 2 code for 11043, the modifier indicator of “1” means that you can append a modifier such as 59 or XS to 11042 to show that the shin debridement is a separate anatomic location from the thigh debridement.

“If the medical record documentation indicates the wounds are in different anatomical sites, and both 11042 and 11043 are properly documented, then 59 is appropriate,” explains Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.