Ob-Gyn Coding Alert

If you notice you applied it to the wrong code, here's what you should do.

Although you may be getting ready to take your spring break, you can't be lax about your modifier 59 claims.

Carriers are still scrutinizing submissions for separate and distinct services, thanks to the Office Inspector General (OIG)'s error rates. But you can prevent paybacks by following this expert advice.

Separate Regions Are Paramount

Pull a sample of your modifier 59 submissions and verify that the claims properly represent a distinct procedural service.

Rule of thumb: Make sure the physician is working in a separate body area before you use modifier 59, experts say.

Example: Your ob-gyn removes a 5cm 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 thetime 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.

Append Modifier 59 to the Secondary Code

Notice how the tumor example above includes appending modifier 59 to the secondary code (49203). The National Correct Coding Initiative (CCI) 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. 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. The study found that 11 percent of claims had modifier 59 attached to the primary code instead of the secondary code, and another 13 percent had modifier 59 attached to both the primary and secondary codes.

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 IUD with cervical cyst removal claim:

Example: An ob-gyn codes a claim as 58301 (Removal of intrauterine device (IUD)) as the patient now wishes to become pregnant (Z30.432, Encounter for removal of intrauterine contraceptive device), and 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)) to remove a large Nabothian cyst on the cervix that is causing pain during intercourse (N88.8, Other specified noninflammatory disorders of cervix uteri and N94.12, Deep dyspareunia). You submit the procedure as:

• 58301-59
• 57500

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (58301) instead of the component or column 2 code (57500).  

Action: "If you notice that you have put modifier 59 on the wrong code, resubmit the claim," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. In the event of an audit, payers should look positively on your proactive stance, she adds. Your corrected claim should look like this:

• 58301
• 57500-59.

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