Oncology & Hematology Coding Alert

Question: I know I don't need separate diagnoses for separate procedures I report with modifier 59, but if I do have separate diagnoses for bundled procedures, does that automatically mean modifier 59 is appropriate?

California Subscriber

Answer: In short, no. Bundled procedures with separate documented diagnoses may meet the criteria for using modifier 59 (Distinct procedural service), but you shouldn't automatically use the modifier in this situation.

CMS recently posted an MLN Matters article clarifying modifier 59 use, including the statement that different diagnoses "are not adequate criteria" for appending 59. You-ll find this rule authoritatively written in Chapter 1, page 14, of the Correct Coding Initiative (CCI) Policy Manual (version 12.3) available online at www.cms.hhs.gov/NationalCorrectCodInitEd/.

The MLN article specifies that for CCI edits, modifier 59's primary purpose "is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes" ("Proper Use of Modifier --59,-" www.cms.hhs.gov/MLNMattersArticles/downloads/SE0715.pdf).

According to the article, you may consider using 59 when you have documentation of procedures or services not normally reported together, including procedures not normally performed by the same physician on the same day that the provider performs at the following:

A different

- session or patient encounter

- procedure or surgery

- site or organ system

OR

A separate

- incision/excision

- lesion or

- injury (or area of injury in extensive injuries).

Example: The article offers the example of column 1/column 2 (formerly comprehensive/component) codes 38221 (Bone marrow; biopsy, needle or trocar) and 38220 (Bone marrow; aspiration only). Although you-ll rarely be able to break this bundle, modifier 59 may be appropriate when the physician performs the procedures:

- on different sites, such as contralateral iliac crests or iliac crest and sternum

- through different incisions, such as for the same iliac crest or

- during different encounters.