Modifier Coding Alert
Answer the Questions in This Chart to Make Correct Modifier 59 Decisions
Guard against overriding every ‘1’ bundle.
You’re not alone if you think that you can break all Coding Initiative (CCI) bundles using modifier 59 (Distinct procedural service). Some coders think that just because their physician performs two separate procedures that CCI bundles with a status indicator of “1,” that modifier 59 breaks the bundle.
Think again. Even veteran coders can fall into the modifier 59 trap. You should not automatically append modifier 59 just because CCI puts a modifier indicator of “1” on a bundle, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, audit manager at CHAN Healthcare in Vancouver, Wash. Modifier 59 is actually the “modifier of last resort,” Bucknam explains.
Here’s why: Incorrectly unbundling without proper documentation can result in payback requests and accusations of fraud.
This handy flowchart will help you determine your modifier options and select the right modifiers when you’re faced with coding two procedures during the same operative session.
1. Does CCI bundle the procedures?
No: Append modifier 51 (Multiple procedures) to the second procedure if your payer requires a modifier. Some payers, such as Medicare, automatically apply modifier 51.
2. Does the CCI bundle have a modifier indicator of “1” or “0”?
1: Go to question 3.
3. Did the physician perform the second procedure during a different session on the same day?
Yes: Append modifier 59 to the Column 2 procedure code.
4. Did the physician perform the procedures at different anatomical locations, sides of the body, or different locations within the same organ?
Yes: Go to question 5.
5. Are modifiers LT/RT or 50 appropriate?
Yes: Report the procedures with either modifier 50 (Bilateral procedure) or LT (Left side) and RT (Right side) appended.
Yes: Go to question 2.
0: You cannot report the two procedures together using modifier 59.
No: Go to question 4.
No: You cannot report the two procedures together using modifier 59.
No: Append modifier 59 to the second procedure code.
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