Neurology & Pain Management Coding Alert

Discover 2 ways the OIG says coders are making big mistakes

Now is not the time to be lax in how you report modifier 59. Carriers are still scrutinizing your separate and distinct service submissions. But you can prevent paybacks by avoiding the following two pitfalls that could land your claims in the OIG's error rates.

Note: In a November 2005 study, the HHS Office of Inspector General (OIG) cast a spotlight on the use of modifier 59 (Distinct procedural service), and the results weren't pretty. The OIG found a 40 percent error rate for modifier 59 in its claims sample.

Confirm Separate Region Before Using 59

Pull a sample of your modifier 59 submissions and verify that the claims properly represent a distinct procedural service. Fifteen percent of the OIG's audited claims using modifier 59 had procedures that weren't distinct because -they were performed at the same session, same anatomical site, and/or through the same incision,- says Daniel R. Levinson, inspector general, in -Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits,- an article posted on the OIG Web site www.oig.hhs.gov/oei/reports/oei-03-02-00771.pdf.
 
Make sure the physician is working in a separate body area before you use modifier 59, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash.

Example: Your neurologist performs a median motor nerve conduction study with F wave (95903, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study) and then an ulnar nerve conduction study without F wave (95900, - motor, without F-wave study). If you don't put modifier 59 on 95900, your payers will assume that both codes apply to the same nerve.

Put 59 on the Secondary Code
 
Notice how the nerve conduction study example above includes appending modifier 59 to the secondary code (95900). The National Correct Coding Initiative (NCCI) publishes a list of comprehensive/component -edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations,- says Laurie Green, CPC, coding and compliance analyst at Group Health Cooperative in Seattle. -Each edit consists of a column 1 and column 2 code.-

How bundles work: If a physician reports the two codes of an NCCI edit for the same beneficiary for the same date of service without an appropriate modifier, the carrier pays only the column 1 code, Green says. The carrier may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit.

Learn From the OIG

Although attaching the modifier to the column 2 code may seem elementary, the OIG found numerous application errors. The study found that 11 percent of claims had modifier 59 attached to the primary code instead of the secondary code, and another 13 percent had modifier 59 attached to both primary and secondary codes.

Close call: Your modifier 59 payment was almost restricted to adhering to the -59 on the second code- guideline. The OIG encouraged carriers to pay claims only when modifier 59 is attached to the secondary code, not the primary, but CMS responded that it lacks the technical ability to put in place such an edit. Such an edit would have rejected payment for the following injection claim: 

Example: A neurologist codes a chart as 64614 (Chemodenervation of muscle[s]; extremity[s] and/or trunk muscle[s] [e.g., for dystonia, cerebral palsy, multiple sclerosis]) and 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch). His documentation shows that he performed the chemodenervation in a different anatomical region from the nerve block. You submit the procedure as:

- 64614-59
- 64400. 

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (64614) instead of the component or column 2 code (64400). Action: -If you notice that you have put modifier 59 on the wrong code, resubmit the claim,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

Your corrected claim should look like this:

- 64614
- 64400-59. 

Bonus: You can test your modifier 59 skills with examples from the CMS- modifier 59 article available online at www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf.