Neurology & Pain Management Coding Alert

If documentation won't support a separate service, don't unbundle

If you're using modifier -59 indiscriminately, you may get your claims paid, but you could be asking for trouble with potential audits and big penalties.
 
To avoid running afoul of CMS regulators, be sure the neurologist's documentation makes clear the distinct and separate nature of the procedure to which you are appending modifier -59

Don't Treat -59 as a Catchall

You should never use modifier -59 (Distinct procedural service) if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant.
 
In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.
 
Coding example 1: For pain relief, the neurologist administers two neurolytic injections to the patient, one each at cervical (62281, Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, cervical or thoracic) and lumbar (62282, ... epidural, lumbar, sacral [caudal]) spinal levels.
 
In this case, because the surgeon provides the injections at separate locations, he is entitled to seek payment for each injection.
 
You shouldn't apply modifier -59 in this case, however: The National Correct Coding Initiative doesn't bundle 62281 and 62282, and you can achieve separate payment simply by appending modifier -51 (Multiple procedures) to 62282. And even this may not be necessary for many payers. "Modifier -51 is falling out of favor with payers," Bucknam says. "In most cases, the payer's software automatically detects 'additional' procedures and reimburses for them accordingly."
 
Coding example 2: In a second case, the neurologist sees an established patient for a scheduled trigger point injection (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]). During the visit, however, the patient complains of new symptoms of muscle weakness (728.87). The neurologist administers the injection, but also conducts an E/M service (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient...) and EMG (95861, Needle electromyography; two extremities with or without related paraspinal areas) for the new complaint.
 
Because payers will generally bundle an E/M service into any injection or other service, you will have to use a modifier to be paid for the neurologist's evaluation of the new symptoms of muscle weakness.
 
Again, however, you should not turn to modifier -59. Rather, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M service code better describes the situation. Therefore, you should report 20552 (for the injection), 95861 (for the diagnostic EMG related to the new problem) and 99213-25 (for the E/M service related to the new problem).

Don't Unbundle Without Cause

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.
 
"[Modifier -59] is overused just to get through the edits," says consultant Annette Grady, CPC, CPC-H, with Eide Bailly in Bismarck, N.D.
 
Indeed, coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. But Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation to back it up.
 
For example: Neurology practices routinely use modifier -59 to override the NCCI edits bundling 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) to 95903 (... motor, with F-wave study).
 
When you should unbundle: During testing for carpal tunnel syndrome, the neurologist provides NCS without F-waves on the ulnar nerve and NCS with F-waves on the median nerve. Because the neurologist provides the different types of testing on two different nerves, you are justified in reporting 95903 and 95900-59 to receive separate payment for the two tests.
 
When you shouldn't unbundle: The neurologist conducts NCS without F-waves on the ulnar nerve. Realizing he requires more data, he performs NCS on the same nerve a second time, but with F-waves. Because the two tests occurred on the same nerve, you may only report the more extensive procedure (95903). Attempting to gain separate reimbursement using 95903 and 95900-59 is an unjustified unbundling of the NCCI edit.

Remember: Payers Are Watching

CMS is now looking closely at -59, Grady believes. While each carrier and payer has different claims-review software, you may safely assume that many carriers will single out claims with modifier -59 for extra scrutiny.
 
The North Dakota Medicaid program actually handles all claims with modifier -59 by hand, Grady adds. "It automatically pops them out," and reviewers go over the claims for medical necessity.