Ob-Gyn Coding Alert

Modifier -59 is for procedures you would not normally report together

When a patient requires a hysterectomy and a separate abdominal repair in the same session, do you report only one code? If the ob-gyn performs an ultrasound and a biophysical profile, do you automatically assume you can't report the profile? If you answered "yes" to either of these questions, you may not be taking advantage of all situations in which you can use modifiers -59 and -51. Read on for more information on these modifiers, which may be helpful when you report related codes on the same claim.

Modifier -59 Applies When Codes Are Close

Ob-gyn coders use modifier -59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date. In general, you should append modifier -59 to procedure codes when the physician:
 

sees a patient during a different session

treats a different site or organ system

sees a patient during a different encounter

treats a different organ system

treats a separate injury.

Modifier -59 is "used when multiple procedures in the same (code areas) are performed at the same time," says Linda Parks, MA, CPC, CMC, CCP, coding specialist in Marietta, Ga.

Example: Let's take the scenario mentioned earlier, in which the physician performs a hysterectomy and separate abdominal repair in the same session. A 35-year-old patient reports to the office with uterine fibroids and a symptomatic enterocele. The ob-gyn performs a complete abdominal hysterectomy and makes a repair to the enterocele via abdominal approach.

You should:

report 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) for the hysterectomy.

report 57270 (Repair of enterocele, abdominal approach [separate procedure]) with modifier -59 attached. The modifier shows the carrier that the hysterectomy and abdominal repair were separate procedures.

Remember: The higher the relative value units (RVUs) for a given code, the more you'll be paid for the procedure. Always attach modifier -59 to the code with the lower RVUs.

Payoff: The RVUs for 58150 (hysterectomy) are 24.63 for facilities, while 57270 (abdominal repair) is worth 19.78 for facilities.

Note: Neither 58150 nor 57270 has nonfacility RVU totals.

Not Sure? Check NCCI

If you're stuck on whether you should bill codes with modifier -59, check the National Correct Coding Initiative (NCCI) edits, Parks says. If the codes you are reporting have indicators of "1" next to them, this means you can append the modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.

Time Saver: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary, experts say. Many private payers do not require a modifier for multiple-procedure scenarios or don't recognize -59 as a legitimate modifier. Check with your individual payer to see if modifier -59 is necessary when reporting multiple-procedure claims.

Tip: 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, Parks says. Then, chart each carrier's policies on -59 so you know whether to use it the next time you file a claim.

Spend Time Now, Avoid Headaches Later

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.

However, don't be afraid to use modifier -59 if you have to -- just make sure you've exhausted all other options and you are using it as it was intended, as the "modifier of last resort."

Use Modifier -51 for Multiple Procedures

When your internist treats a patient who requires multiple procedures, you would include modifier -51 (Multiple procedures) on your claim.

Modifier -51 is "an informational-type modifier ... for use on the second, third, etc., surgical procedure performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

Example: Your ob-gyn performs a complete ultrasound on a 26-year-old patient in her 18th week of pregnancy. The doctor also performs a biophysical profile in the same session. You should:
 

report 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transab-dominal approach; single or first gestation) to represent the ultrasound.

attach modifier -51 to 76818 (Fetal biophysical profile; with non-stress testing) to represent the biophysical profile.

Why? The modifier is appropriate because it shows that the two procedures are actually separate and that you're not "double-dipping" with your claim, Riesser says. In other words, modifier -51 indicates to the insurance company that the procedures were unrelated to each other.

Check RVUs Before Ordering Codes

On modifier -51 claims, the code that stands alone is the code that will be fully paid, so make sure you attach modifier -51 to the code with the lower RVU. "Modifier -51 prevents the insurance company from changing the order of your codes because the most expensive procedure should be listed first," Riesser says.

Payoff: The RVUs for 76805 are 3.61 for non-facilities, while 76818's RVUs are 3.20 for nonfacilities.

Note: Neither 76805 nor 76818 has RVUs for facilities.

Remember: While reimbursement rates for codes with modifier -59 attached vary by payer, expect half the normal reimbursement for codes with modifier -51 attached. (Most insurance companies have adopted Medicare's policy paying 50 percent for codes with modifier -51 attached.)