Neurology & Pain Management Coding Alert

Properly applying modifier 59 is essential for reimbursement when medical necessity and the documentation support its use (such as nerve conduction studies to multiple sites), but you should never report modifier 59 carelessly or merely to get claims paid. Payers know that this modifier is ripe for abuse, and time and again modifier 59 use comes under increased scrutiny from Medicare, the HHS Office of Inspector General (OIG) and other payers.

Here are four expert-approved ways to bulletproof your modifier 59 claims.

You may use modifier 59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure the neurologist 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 to your claim when a physician:

- 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: Your neurologist completes an EEG and sleep study on the same patient the same date. Payers may object because EEG recording is part of a sleep study -- but not if the physician completes the tests for different diagnoses. Append modifier 59 to the procedure code and include the multiple diagnoses the neurologist documents to support separate billing.

CPT instructions indicate that you should not report 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 programs for the American Academy of Professional Coders, the coding organization in Salt Lake City.

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 identified as "separate procedures" by CPT will be subject to extensive bundles by CCI, Cobuzzi says.

When you may unbundle: Even when documentation supports a separate site, excision, patient encounter, etc., don't expect to automatically override a CCI edit using modifier 59. Before filing your claim, check the correct coding modifier indicator for the bundled code pair you wish to report.

Here's how: Each CCI code-pair edit includes a correct coding modifier indicator of "0" or "1." You can find the correct coding modifier as a superscript placed to the right of the column 2 code in each bundled code pair. Here's what the indicators mean:

- A "0" indicator means that you may not unbundle the edit combination under any circumstances, according to CCI guidelines.

- A "1" indicator means that you may use a modifier to override the edit if the procedures are distinct from one another (if the procedures also meet any of the conditions for modifier 59 use outlined above).

When you append modifier 59 to break a CCI edit, or when you bill separately for a CPT-described "separate procedure," you should always append the modifier to the "lesser" or "separate procedure" code (typically the code in column 2).

A classic example: You report a motor nerve conduction study with 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) for one nerve and 95903 (-motor, with F-wave study) for another nerve. Distinguish the procedures by appending modifier 59 (Distinct procedural service) to 95900.- (You should not append 59 to 95903.)

Remember this: The order in which the physician performs the procedures doesn't determine which code receives modifier 59.

Only append modifier 59 to a procedure if you are certain of the involved procedures- distinct nature, Cobuzzi says. Never report modifier 59 simply to override CCI bundles and get paid.

Justified unbundling: You may report two procedures separately, using modifier 59 to break the CCI bundle, if the procedures occur at different locations within the body.

Note also that you may use HCPCS level II location modifiers LT (Left side) and RT (Right side) to make your claim more specific and further support separate payment for services.

Unjustified unbundling: If the procedures occur at the same location, you should not report the procedures separately because this is just the type of billing that the CCI edits attempt to prohibit.

Your best bet? Let common sense prevail: Did the second procedure require a separate approach, significant extension of the initial approach, and a separate site? If so, you can treat it as an additional procedure. If the second procedure involved only limited service in the area of the primary procedure and minimal additional time and effort, don't code it separately.