Ob-Gyn Coding Alert

Reviewers automatically check -59 claims for necessity Appending modifier -59 to this round of National Correct Coding Initiative (NCCI) ob-gyn procedure edits with a status indicator of "1" may be an easy fix to receive separate reimbursement - but you could attract unwanted regulatory attention.

Here's the scoop on how you can maximize modifier -59 (Distinct procedural service) use and your reimbursement, and minimize scrutiny.
 
Avoid Treating -59 as a Catchall Don't fall into the trap of using modifier -59 if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant. You should be using modifier -59 only as a last resort.

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.

"[Modifier -59] is overused just to get through the edits," says Annette Grady, CPC, CPC-H, a consultant with Eide Bailly in Bismark, N.D.

Coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC,  CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

But Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation to back it up. Use Modifier -59 to Signify Distinct Procedures You should use modifier -59 only when no other modifier applies to services performed by the same physician on the same day, and it is used to indicate that a procedure that would normally be bundled with other procedures was distinct during this surgical session. It is primarily used with codes that are designated as "separate procedure" in the CPT book, but it may be used in other circumstances as well.

Most often, it will be added to a code that is a separate procedure performed for a reason unrelated to the primary procedure. You may also use modifier -59 with the primary procedure if that procedure has the higher RVU. CPT states that this modifier is "appropriate under certain circumstances." They include:

1. A different session or patient encounter. This means the ob-gyn provides a distinct service during a different patient encounter - even though a similar procedure may be performed. For example, an ob-gyn performs a D&C (58120) in the morning, and the patient continues to bleed throughout the day. So the ob-gyn performs a hysteroscopy D&C that evening (58558). In this case, the hysteroscopy procedure has a higher RVU, so the code order is 58558, 58120.

"You may [...]