Ob-Gyn Coding Alert

This ob-gyn example will demonstrate both incorrect and correct solutions.

Although you may be in the midst of planning your summer vacation, you can't be lax about your modifier 59 (Distinct procedural service) 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.

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 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.

Example: Your ob-gyn removes a 4 cm tumor on the upper abdominal wall (49203, Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less) 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 49203 (to change it to 49203-59), 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 (49203). The Correct Coding Initiative 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, experts say. Each edit consists of a column 1 and column 2 code."

Review: If you report the two codes of a CCI edit for the same beneficiary for the same date of service without an appropriate modifier, the carrier pays only the column 1 code. The carrier may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit. Although appending the modifier to the column 2 code may seem elementary, the OIG found numerous application errors.

Close call: Your modifier 59 payment was almost restricted to adhering to the "59 on the second code" guideline. The OIG encouraged carriers to pay claims only when modifier 59 is appended to the secondary code, not the primary, but CMS responded that it lacks the technical ability to put in place such an edit. Such an edit would have rejected payment for the following Doppler claim:  

Example: An ob-gyn codes a claim as 76828 (Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study) and 76820 (Doppler velocimetry, fetal; umbilical artery). His documentation shows that he performed the fetal Doppler echocardiography (76828) to detect fetal cardiac disease because the mother has diabetes (648.03, Diabetes mellitus; antepartum condition or complication) and did the umbilical artery velocimetry (76820) because the fetus has intrauterine growth retardation (656.53, Poor fetal growth; antepartum condition or complication). You submit the procedure as:

• 76820-59
• 76828.

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (76820) instead of the component or column 2 code (76828).

Action: "If you notice that you have put modifier 59 on the wrong code, resubmit the claim," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

Your corrected claim should look like this:

• 76820
• 76828-59. 

Bonus: You can test your modifier 59 skills with examples from the CMS modifier 59 article available online at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads//modifier59.pdf.

ICD-10: When your diagnosis system changes, you will have the following equivalents:

• Code 648.03 will become O24.0-- (Pre-existing diabetes mellitus, type 1, in pregnancy) or O24.1-- (Pre-existing diabetes mellitus, type 2, in pregnancy) with the fifth and sixth digits specifying trimester. You also have unspecified options, but you should always code to the highest specificity.
• Code 656.53 will become O36.5-- (Maternal care for known or suspected placental insufficiency) with the fifth digit specifying trimester and the sixth digit specificity fetus. You also have unspecified options, but you should always code to the highest specificity.