Oncology & Hematology Coding Alert

Question: Should I always append modifier 59 to the lower-valued code of an NCCI edit pair?

Washington Subscriber

Answer: In most cases, you append modifier 59 (Distinct procedural service) to the lower-valued code, but that's not always the case. A better rule to follow is this: Append modifier 59 to the column-two code (formerly known as the component code) of a code pair edit.

The National Correct Coding Initiative (NCCI) mutually exclusive code list contains edits consisting of two codes (procedures) that a physician cannot reasonably perform together based on the code definitions or anatomic considerations. Each edit consists of a column-one (comprehensive) and column-two (component) code. If you report both codes on the same service date for one beneficiary without an appropriate modifier, Medicare will pay only the column- one code.

When clinical circumstances justify appending a modifier to the column-two code of an edit, the carrier may allow payment of both codes. Tip: According to CMS, modifier 59 may be appropriate when the two procedures are performed at separate patient encounters or at separate (noncontiguous) anatomic sites.

The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.