Neurology & Pain Management Coding Alert

Your modifier 59 claims will pass muster thanks to this quick refresher.

When it comes to modifier 59, youre stuck between a rock and a hard place: Its essential for reimbursement when medical necessity and the documentation support its use, but Medicare, the HHS Office of Inspector General (OIG), and other payers scrutinize its use.

Try these four expert methods to use your modifier 59 when you should.

1. Append 59 to the Secondary Code, Not Primary

Use modifier 59 (Distinct procedural service) to identify procedures distinctly separate from any other procedure your neurologist provides on the same date.

CPT and Correct Coding Initiative (CCI) Chapter 1 guidelines indicate that you may append modifier 59 to your claim when your neurologist:

" 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.

When appending modifier 59 to break a CCI edit or bill separately for a CPT-described separate procedure,

you should always append the modifier to the lesser or separate procedure code -- usually the code in column 2, states Vicky V. ONeil, MHA, CPC, CCS-P, owner of The Hazlett Group in Birmingham, Ala., in an audioconference for Audioeducator.com on modifier 59.

The order in which the physician performs the procedures doesnt determine which code receives modifier 59.

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 a different nerve or nerve branch. To distinguish the diagnostic studies, append modifier 59. This lets the payer know that your neurologist performed separate and distinct diagnostic studies on two different nerves or nerve branches.

You should not append 59 to 95903, which is considered to be the comprehensive service. The descriptor indicates 95903 includes the late response Fwave study performed on the same nerve, as well as the standard motor nerve conduction study.

Warning: Never append modifier 59 to any E/M service code, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPCP, CIMC, CHCC, with Healthcare Solutions in Tinton Falls, N.J.

2. Look to CCI for Options

If you wonder if two procedures are subject to bundling edits, 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.

Unbundling rules: Even when documentation supports a separate site or patient encounter, dont expect to automatically override a CCI edit using modifier 59. Before you file a claim, check the correct coding modifier indicator for the bundled code pair you wish to report.

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. Heres 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).

3.Watch for More Specific Modifiers on Different Patient Encounters

Heres the situation: Your neurologist completes an EEG and polysomnography on the same patient on the same date. Some payers may object to your reporting the tests together because EEG recording is part of a sleep staging study -- but not if the physician completes the tests during different sessions or encounters. Append modifier 59 to the EEG code if your neurologists documentation supports the separate billing.

CPT instructions indicate that you should not report modifier 59 if another, more specific modifier, like modifier 58 (Staged or related procedure or service by the same physician during the postoperative period), 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period), 79 (Unrelated procedure or service by the same physician during the postoperative period), or 91 (Repeat clinical diagnostic laboratory test) describes the separate patient encounter or session better.

4. Never Unbundle . . .Without Reason

Append modifier 59 to a procedure only if youre  certain of the involved procedures distinct nature, Cobuzzi says. Never report modifier 59 simply to override CCI bundles and get paid.

Take note: You can report two procedures separately, using modifier 59 to break the CCI bundle, if the procedures occur at different locations within or on the body. Per the CCI Manual, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ.

If appropriate, you can instead use HCPCS level II location modifiers LT (Left side) and RT (Right side) or the hand (FA, F1-F9) or foot (TA, T1-T9) modifiers 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 exactly the sort of billing that CCI edits prohibit.

Check: 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, dont code it separately.