Oncology & Hematology Coding Alert

Hasty use of '1' may make waste of your -59 claims

Modifier -59 may seem like a cure-all when your oncologists perform more than one distinct procedure during a single session, but think twice before you unbundle any code pair because you could trigger government audits.
  
Watch out: In its recently released 2005 Work Plan, OIG at the Department of Health and Human Services stated that it intends to scrutinize claims that include modifiers used to bypass NCCI edits. Tip: To avoid running afoul of CMS regulators, always be sure the physician's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59 (Distinct procedural service).

Although several modifiers allow practices to unbundle National Correct Coding Initiative (NCCI) edits, oncology practices most often choose modifier -59 in order to separate code pairs.

Follow our experts' advice to determine when you should - and should not - append modifier -59 to your claims.

Modifier -59 Works When Codes Are Close

Oncology coders use modifier -59 to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.

Think of it this way: Modifier -59 tells the payer that the procedures were not components of one another but were both medically necessary and separate from one another, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Beware: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary. If you overuse this modifier, you may indicate routine unbundling of services to insurers, and they can initiate a review based on this suspicion, coding experts say. Your documentation must clearly identify the medical necessity and separateness of the unbundled service.

If Other Modifiers Will Do the Job, Avoid -59

You should never use 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.

In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.

Note: See our modifier -59 decision tool on page 37 to help you determine when you should select modifier -59 rather than other modifiers.

Coding example: The radiation oncologist performs a simple brachytherapy administration on the same date of service as the one she performed earlier on a patient who is receiving high dose rate (HDR) treatments each twice daily (BID).

In this case, you should report 77781 (Remote afterloading high-intensity brachytherapy ...) with modifier -76 (Repeat procedure by same physician) because the radiation oncologist repeated the same procedure. You may also append modifier -26 to designate the professional component.