Neurosurgery Coding Alert

Modifier -59 (distinct procedural service) is important because it enables neurosurgeons to receive separate reimbursement for procedures that are usually bundled if provided on the same date of service, but that in a particular instance were distinct or independent of one another. But just as proper use of modifier -59 can increase a surgeon's bottom line, improper use or abuse can lead to denied claims, audits or allegations of fraud.

According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." In essence, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, owner and CPC trainer for A+ Medical Management and Education in Absecon, N.J, modifier -59 tells the insurer, "Although these services/procedures appear related, they are, in this case, separate." Such circumstances may include:

 

A different session or patient encounter.
 

A different procedure or surgery.
 

A different site or organ system (perhaps the most common use of the modifier).
 

A separate incision/excision, lesion or injury or area of extensive injury not ordinarily encountered or performed on the same day by the same physician.

Specifically, modifier -59 is used to unbundle national Correct Coding Initiative (CCI) code pair edits. For instance, the surgeon performs a lumbar decompression followed by a lumbar microdiskectomy at a different level. Each procedure was associated with a different diagnosis. The coder may report 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) and 63030 (laminectomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) together with separate diagnoses. CCI bundles these procedures, but the edit includes a "1" indicator. Therefore, modifier -59 can be attached to the microdiskectomy to indicate that it was performed at another location.
 
But if the surgeon extends the laminectomy to remove a disk at the adjacent level, modifier -59 may not be used because the procedure is not occurring at a separate anatomical area.

Modifier -59 is used frequently to override CCI edits in neurosurgical coding. For instance, 22630 (arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) includes laminectomy, facetectomy and diskectomy to prepare the interspace for posterior lumbar interbody fusion, and CCI bundles it with 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). Once again, the edit includes a "1" indicator, and a modifier may be used "to differentiate between the services provided" at different times or at different locations on the body. For instance, if a decompression beyond that required for site preparation related to the posterior interbody fusion is performed, or the laminectomy is done at a different level, you may report 63047 with modifier -59 appended.
 
Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code, Jandroep says. Note that only CCI edits with a status indicator of "1" may be unbundled using modifier -59. Those code combinations with a status indicator of "0" (of which neurosurgical coders would encounter few) may not be unbundled under any circumstances. Modifier -59 need not be appended if the multiple procedure codes you are billing for the same patient on the same day are not bundled by CCI. For more information on CCI edits, see Neurosurgery Coding Alert, August 2001.
 
As a second example, CCI bundles 61795 (stereotactic computer assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) to many neurosurgical codes but will allow separate payment with the craniotomy codes (e.g., 61304-61305, 61556-61557, etc.) if modifier -59 is appended to the imaging code.

CPT instructs providers that modifier -59 is not a "catchall" and should be reported only if no other, more specific modifier applies (e.g., modifiers -51 [multiple procedures], -78 [return to the operating room for a related procedure during the postoperative period] or -79 [unrelated procedure or service by the same physician during the postoperative period]), says Sharon Tucker, CPC, president of Seminars Plus, a consulting firm specializing in coding, documentation and compliance issues, in Fountain Valley, Calif.
 
For example, a neurosurgeon performs a craniotomy for tumor excision (61510) and later that same day must reopen to evacuate an subdural hematoma (61312). While the second procedure would normally be bundled according to CCI edits, and while the -59 could override this edit, it is more appropriately described as a related procedure during the postoperative period and should be billed with modifier -78.
 
Note: For more information on modifiers -78 and -79, see Neurosurgery Coding Alert, November 2001.
 
Also, modifier -59 should not be appended to E/M codes, Tucker warns. Rather, to be paid separately for an E/M service that is bundled into a global surgical package, the service provided must meet the definition of, and properly append, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Jandroep and Tucker agree that unlike some modifiers, including -51, modifier -59 should not lead to a reduction in reimbursement. Do not reduce your fees when billing, and appeal if the payer reduces your modifier -59 claims. In some cases, reimbursement with modifier -59 is carrier- or situation-driven. If this is the case, you may protest the reduction, but be sure to get the carrier's guidelines in writing and follow them.
 
If modifier -59 is used with surgical modifiers such as -51, -78 or -79, be sure to append the -59 modifier last. Also, modifier -51 should be used in addition to the -59 modifier if the -51 would otherwise be correct. If modifier -51 is used with -59, however, there should be a reduction in payment. Just because many carriers pay at full value doesn't mean it is correct, and there is no guarantee that payers won't seek later to recoup payments made at full value that should have been reduced as secondary procedures.
 
Because of modifier -59's ability to unbundle CCI edits and increase payments, it may receive special scrutiny from payers. Modifier -59 should not be used indiscriminantly as a way to increase payments or "protest" CCI coding edits. Although it isn't necessary to include full notes with every claim as one would with modifier -22 (unusual procedural services), be aware that because this modifier can be used to override most CCI edits and thereby increase payment, the insurer may request additional documentation. Therefore, always keep thorough notes available to substantiate the use of modifier -59 (whether to collect a claim or in case of an audit). Also, using different diagnoses when applicable for each CPT code will help to establish medical necessity.