Neurosurgery Coding Alert

Be sure to check CCI for a -1- modifier indicator

Properly applying modifier 59 (Distinct procedural service) is essential for reimbursement when medical necessity and the documentation support its use, 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 others.

Here are four expert-approved ways to bulletproof your modifier 59 claims. 1. Recognize When 59 Applies You may use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician 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 when your surgeon:

- 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: The neurosurgeon performs arthrodesis at L1/L2 (22630, Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar), followed by laminectomy at L4 (63047, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar).

In this case, you may report 22630, as well as 63047-59. CPT does specify that 22630 includes laminectomy and/or discectomy to prepare the interspace for posterior lumbar interbody fusion. Because the L4 laminectomy occurs independently and at a separate location from the L1-L2 arthrodesis, however, you may append modifier 59 to receive separate payment for 63047.

CPT indicates that you should not use 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. 2. Look to CCI for Bundles, Options 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., you may [...]