Oncology & Hematology Coding Alert

Question: Different insurance companies tell me different things about where to place modifier 59. Should I append it to the primary procedure or the secondary one?

Pennsylvania Subscriber

Answer: If you have instructions in writing from the payer, experts advise you to follow those instructions. However, in the absence of instructions to the contrary, you would append modifier 59 (Distinct procedural service) to the column 2 code of the Correct Coding Initiative (CCI) edit pair.

Rationale: Medicare has at least two instructions regarding modifier 59 placement:

1. On CMS's CCI edits Web page (www.cms.hhs.gov/NationalCorrectCodInitEd/), there's a link to FAQs at the bottom. The FAQ with ID 3517 instructs providers to append modifier 59 to the column 2 code.

2. Medicare Claims Processing Manual, Chapter23, Section 20.9.1.1.B, says to append modifier 59 to the "secondary, additional, or lesser procedure(s) or service(s)."

Some experts advise always appending modifier 59 to the column 2 code while others say to use it on the lower priced (lesser) procedure, which is often the column 2 code. But, again, if you have instructions in writing from your payer, let those guide your choice.

Example: Suppose your documentation supports reporting 77427 (Radiation treatment management, 5 treatments) and 77786 (Remote afterloading high dose rate radionuclide brachytherapy ...). CCI has edits placing 77427 in column 2 and 77786 in column 1 because brachytherapy code fees already include payment for management services. But you may override the edit if the patient requires both brachytherapy and external beam radiation treatment (and consequently management of external treatment) during the same time period. In most cases, you'll append modifier 59 to 77427, the column 2 code. Medicare's national rate for 77427 is roughly $194 and for 77786, it's $549.