Ob-Gyn Coding Alert

Learn how you can save your claim department's time

If you-re still treating modifier 59 as a catchall, you could be attracting unwanted regulatory attention. Kick these three myths and maximize your modifier 59 (Distinct procedural service) use as well as your reimbursement.

Myth 1: Treat Modifier 59 as a Safety Net

Don't fall into the trap of using modifier 59 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. You should use modifier 59 only as a last resort.

Bottom line: Append modifier 59 to a claim only if you are certain of the distinct nature of the procedures you are reporting, and never simply to override Correct Coding Initiative (CCI) bundles and get paid.
-Modifier 59 is overused just to get through the edits,- says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network and executive officer on the AAPC's National Advisory Board.

Coders often turn to modifier 59 because -it unbundles nicely,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, coding analyst with CodeRyte Inc. in Bethesda, Md.

But Jandroep cautions coders to remember that appending any modifier means you-re saying you have the documentation to back it up.

Myth 2: If Other Modifiers Work, Still Rely on 59

Not true. You should use modifier 59 when no other modifier applies to services performed by the same physician on the same day. This modifier specifically indicates that a procedure that your payer would normally bundle with other procedures was distinct during this surgical session.

Be smart: Each time you are unsure whether a carrier accepts modifier 59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Then, chart each carrier's policies on 59 so you know whether to use it the next time you file a claim.
Making these phone calls may take a little time initially, but once you get a chart with each insurance company's policy on modifier 59, your claims department will be streamlined dramatically.

Myth 3: Only 59 on -Separate Procedure- Codes

Although you-ll primarily use modifier 59 with codes that CPT designates as -separate procedure,- you may still use it in other circumstances as well.
For instance, you may also use modifier 59 with the primary procedure if that procedure has the higher relative value unit (RVU). CPT states that this modifier is -appropriate under certain circumstances.- They include:

1. A different session or patient encounter. This means the ob-gyn provides a distinct service during a different patient encounter -- even though she may perform a similar procedure. For example, an ob-gyn performs a D&C (58120, Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) in the morning, and the patient continues to bleed throughout the day. So the ob-gyn performs a hysteroscopy endometrial ablation that evening (58563, Hysteroscopy, surgical; with endometrial ablation [e.g., endometrial resection, electrosurgical ablation, thermoablation]).

In this case, the hysteroscopy procedure has a higher RVU, so the code order is 58563, 58120-59.

You must append the modifier to the D&C procedure code even though CPT does not list it as a -separate procedure.- This is because payers will bundle the D&C into the ablation procedure unless you meet this criterion.

2. A different procedure or surgery. For example, a patient has uterine fibroids, and the ob-gyn performs a TAH/BSO (58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]).

The patient also has a tumor imbedded in the upper abdominal wall that must be removed, so you also report 49200-59 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas).

3. A different anatomic site or organ system. The ob-gyn performs a vulvar lesion biopsy (56605, Biopsy of vulva or perineum [separate procedure]; one lesion) and, at the same session, he removes a 2.0-cm benign cystic lesion on the inside of her thigh (11402, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm). Then you should report 11402, 56605-59.

4. A separate incision/excision. An ob-gyn performs a laparoscopy with LSO (left salpingo-oophorectomy, 58661, Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) and an aspiration of a cyst on the right side (49322, Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]). In this case, you should report 58661, 49322-59.

5. A separate lesion. A patient has an ovarian abscess and an ovarian cyst. The surgeon performs drainage of the ovarian abscess (58820) on the first ovary and then drains the ovarian cyst on the other ovary (58800-59, Drainage of ovarian cyst[s], unilateral or bilateral [separate procedure]; vaginal approach).

6. A separate injury. Use modifier 59 if an injury occurs during a procedure and that injury necessitates another procedure. For example, during an abdominal procedure, the ob-gyn must repair an inadvertently torn bladder. The ob-gyn reports the primary procedure with 51860-59 (Cystorrhaphy, suture of bladder wound, injury or rupture; simple). However, Medicare will not reimburse the ob-gyn for repairing an inadvertent injury.