Medicare Compliance & Reimbursement

Question: Other than modifier 59 (Distinct procedural services), which other modifiers can I use to separate CCI edits when warranted?

Answer: 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.

CMS Transmittal 1136, released on Nov. 1, 2012, announced that you can use the following modifiers to override a CCI edit with a modifier indicator of “1” effective Jan. 1, 2013:

• LM (Left main coronary artery)
• RI (Ramus intermedius coronary artery)
• 24 (Unrelated evaluation and management service by the same physician or Other Qualified Health Care Professional during a postoperative period)
• 57 (Decision for surgery).

Whereas modifiers LM and RI are mainly used by heart surgeons, the other two modifiers are quite familiar to most other coders. Both modifiers 24 and 57 can be appended 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).