Ob-Gyn Coding Alert

Modifier -59 (distinct procedural service) is often appended incorrectly or overlooked in favor of modifier -51 (multiple procedures). In the ob/gyn or any specialty setting, this can result in denied claims and lost revenue.

Modifier -59 essentially unbundles procedures. It is the coders and the physicians way of saying to the carrier, Yes, I know procedure B is normally bundled into procedure A, but take a look at this case, which justifies additional reimbursement for additional work done. If the physician can show through his or her operative notes that a distinct procedural service occurred, many commercial carriers will honor the modifier and pay for the additional procedure.

Dont Confuse -59 With Multiple Procedures

Modifier -59 is easily confused with -51. The difference is that -51 is used for procedures that are not normally bundled, but are stand-alone procedures. The -51 modifier simply acknowledges to the carrier that you performed multiple services on the same day and that you anticipate a reduction in fees (generally 50 percent on the second procedure, more on subsequent procedures). Use modifier -59 when you are trying to say that the additional procedure (which is normally an integral part of another procedure performed that day) was distinct and should be allowed to be billed and paid separately.

CPTs rules on modifiers clarify the distinction between the two. Modifier -59 is appended when the procedure identified by CPT as a separate procedure involves:

A different session or patient encounter;

A different procedure or surgery;

A different site or organ system;

A separate incision/excision;

A separate lesion; or

Treatment of a separate injury (or area of injury in extensive injuries).

Modifier -51 indicates multiple procedures that would not normally be bundled together anyway, and is used when:

Multiple medical procedures are performed at the same session by the same provider;

Multiple, related operative procedures are performed at the same session by the same provider;

Operative procedures are performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy; or

A combination of medical and operative procedures is performed at the same session by the same provider.

An Ob/gyn Vignette Using -59

The following ob/gyn scenario, offered by Melanie Witt, RN, CPC, MA, an independent ob-gyn coding educator, illustrates the proper use of modifier -59.

Dr. Morris performed a sonohysterography (76831, hysterosonography, with or without color flow Doppler) on a patient who had presented with symptoms of prolonged menstrual bleeding. An intrauterine polyp was noted during the sonogram. The patient presented a week later for outpatient surgery for a hysteroscopic resection of the polyp and dilation and curettage (58558, hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). At the end of hysteroscopy, a lesion was noticed high in the anterior vaginal fornix. The lesion is excised and biopsied.

Per the Health Care Financing Administrations (HCFA) Correct Coding Initiative (CCI), excision and biopsy of the vaginal polyp (57100, biopsy of vaginal mucosa; simple [separate procedure]) is bundled with 58558*, the hysteroscopy. HCFA took great pains to include most biopsies as bundled services because they have a general rule that biopsies at the time of surgery are not paid separately under most circumstances, explains Witt. But there are several reasons why in this case the excision and biopsy of the vaginal lesion can be billed separately. For starters, it was a different excision from the hysteroscopic removal. The lesion was noticed on a different site from the original operative site, so its removal was an entirely different procedure, she says. Under these circumstances, Medicare will allow the bundle to be bypassed with the use of modifier -59. Per that explanation, the codes would read as follows:

The primary claim is for 58558 with no modifiers. On the second line of the claim form, the additional excision and biopsy is coded 57100-59-51 (biopsy of vaginal mucosa; simple [separate procedure]). Some payers may require only the -59 modifier to be used, but others may require that the -51 modifier also be added because their computer processing system cannot pay the claim properly without it.

Witt explains that the diagnostic codes link to the procedure codes as follows: The claim form is going to have three different diagnostic codes, 620.8 (other noninflammatory disorders of ovary, fallopian tube, and broad ligament) for the diagnoses of the intrauterine polyp; 626.2 (excessive or frequent menstruation) for the menorrhagia; and 623.7 (polyp of vagina) for the vaginal polyp. The primary code (58558) is linked to the first two diagnoses 620.8 and 626.2. The secondary procedure code (57100) is linked to the third diagnosis code, 623.7.

Use -59 Sparingly

Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Physician Coding and Compliance Consulting, a coding and reimbursement firm based in Manassas, Va., says that although modifier -59 can be helpful in obtaining additional reimbursement under the proper circumstances, it is a red flag to insurance carriers. The -59 modifier will get you around many bundled codes, but you dont want to just put a -59 on everything, or you will bring on an audit, she says. Castillo says that coders should have the most recent copy of HCFAs CCI because it lists CPT codes that may never (mutually exclusive procedures) or should only infrequently (Medicare comprehensive coding edits) be billed together. The carrier, whether Medicare or private, is going to match your claims against CCI to determine their validity, Castillo adds.

There are situations when a coder might be tempted to use the -59 modifier, but to do so would be inappropriate. For instance, a physician performs a total abdominal hysterectomy (TAH) 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) and encounters one ovary that is quite dense and full of adhesions. Many physicians and coders think that because of the extra time involved in that difficult oophorectomy, they can bill for a separate oophorectomy and add the -59 modifier, when they should at the most be adding a -22 modifier to the TAH code, says Castillo. The -22 modifier, for unusual procedural service, signals the carrier that extra time and work were involved in the primary procedure. And even the -22 modifier should be used only when the operative note supports the extra time. Improper use of either the -59 or the -22 can result in the entire claim being rejected and, ultimately, trigger an audit.