Ob-Gyn Coding Alert

Here's how to avoid putting this modifier on the incorrect code

Although you may be getting back into the swing of things after your summer vacation, you can't be lax about your modifier 59 claims.

Carriers are still scrutinizing submissions for separate and distinct services, thanks to the OIG's error rates. But you can prevent paybacks by using these two tips.

Note: In a November 2005 study, the HHS Office of Inspector General 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. Tip 1: Determine Separate Regions 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.

Rule of thumb: 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 ob-gyn removes a large tumor on the upper abdominal wall (49200, Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas;) at the time of a hysterectomy with lymph node sampling (58200, Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]).
 
If you don't put modifier 59 on 49200 (to change it to 49200-59), your payers will consider the tumor excision part of the hysterectomy if they apply Medicare's bundling edits. In this case, while the ob-gyn removes the tumor through the same incision, it is located in a different site within the abdominal cavity. Tip 2: Put 59 on the Secondary Code
 
Notice how the tumor example above includes appending modifier 59 to the secondary code (49200). The National Correct Coding nitiative 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.-

Review: If you report the two codes of [...]