Medicare Compliance & Reimbursement

Practices to heed the rules when using modifier 59 to separate CCI edits -- or else, carrier warns Trying to bypass CCI edits? Append modifier 59 to the wrong code and you can kiss your reimbursement goodbye. Medicare payers are taking a new, firmer stance on modifier 59 use. Highmark Medicare, a Part B payer in four states, issued a strongly-worded alert last week reminding you to keep a close eye on those Correct Coding Initiative (CCI) edits. What you already know: Medicare rules state that you can separate certain CCI bundles by appending a modifier, such as 58 (Staged or related procedure or service by the same physician during the postoperative period) or 59 (Distinct procedural service) to the bundled code. What you may not know: You cannot append modifier 59 to separate every CCI bundle. When another modifier (such as 58) is more appropriate, stick with that one (see next page for tips on how to select the correct modifier). Plus: Some practices have been appending the modifier to the primary procedure code, rather than the secondary procedure. But to code properly, you should append the modifier to "the secondary, additional, or lesser procedure(s) or service(s)" according to Highmark's missive. Don't forget: CCI denotes the "lesser" procedure by placing it in column II of the CCI edit list. "The fee for the codes is not necessarily the indicator of which is a column I or column II code, because a column II code
can carry a higher fee than the column I code," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. "When a combination is eligible for bypass and the 59 modifier is improperly reported with the column I rather than the column II code, the edit will not be bypassed and the column II code will be denied," High-mark notes in its alert. Example: Your physician performs a motor nerve conduction study (NCS) without F-waves (95900) for one nerve and an NCS with F-waves (95903) for another nerve. Distinguish the procedures by appending modifier 59 to 95903, since it is the bundled code. Next step: Refer to the flow chart on the next page when you aren't sure which modifier is your best bet.