Oncology & Hematology Coding Alert

Modifier -59 (distinct procedural service) is sometimes referred to as "the modifier of last resort," and is incorrectly used to garner payment for services that are normally bundled. Appending modifier -59 to a procedure that is normally bundled with a more complex procedure will likely result in payment, but that doesn't mean it is justified. Oncology practices must be sure that modifier -59 use is based on documentation that shows that two procedures performed on the same day should be paid separately, says Paula Stinecipher, CPC, CPC-H, co-founder and vice president of AlphaQuest, LLC, a healthcare services firm in Atlanta. 
 
"Modifier -59 is one of the most misunderstood modifiers," Stinecipher adds. "It seems more often than not that when practices get denied for a procedure, they resubmit it with modifier -59," she says.
    
While modifier -59 may result in payment, it may not be deserved. And if it is used incorrectly it may trigger a closer look at your practice and the payer will likely ask for their money back.
 
Modifier -59 was created to identify multiple services provided to a patient on the same day by the same provider. Without the modifier it may appear that the services were incorrectly coded because the procedures should have been reported using only one code. The modifier tells payers that there is a legitimate reason for separate payment. A common bundled service in oncology that is sometimes paid separately is hydration therapy, which is normally bundled with 96410 (chemo-therapy administration, intravenous; infusion technique, up to one hour).

Using Modifier -59 Safely
  
 
Sometimes hydration therapy can be paid separately, says Nancy Giacomozzi, manager of P.K. Administrative Services in Lakewood, Colo. Appending modifier -59 to 90780 (intravenous infusion of therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) tells the payer that saline was administered prior to chemotherapy administration, rather than as part of the delivery of chemotherapy.
 
The danger of this modifier is that appending it will garner payment whether saline was used for hydration therapy or with chemotherapy. Appending modifier -59 will likely prompt a payer to treat 96410 and 90780 as separate procedures because the modifier will bypass payer edits that would have denied 90780 if it were reported on the same day as 96410. Payer edits, such as Medicare's Correct Coding Initiative (CCI), determine which codes may be billed separately and which must be bundled with more complex procedures.
 
In chemotherapy administration, fluids such as saline or dextrose solutions may be needed to maintain line patency or to flush lines between different agents given at the same session. Infusion of these fluids should not be separately billed. If fluid administration is medically necessary for therapeutic reasons (e.g., hydration or protection of renal function) in the course of a transfusion or chemotherapy, it could be separately billed with modifier -59. 
 
Modifier -59 should represent a different session, surgery, anatomical site, agent, lesion, injury or injury area. Before appending it, coders should be sure that documentation of the above is in the patient record. In reviewing patient records for clients, Parman has often found that modifier -59 was appended to a procedure code without documentation to support its use. In many of those cases, billing staff claimed the modifier was justified because payers allowed it to be used and they were getting paid. This is not correct coding.

Use Modifier -59 for Multiple Agents
  
 
Other examples of using modifier -59 include appending it to codes describing chemotherapy administration by multiple routes, the most common being the intravenous route. For a given agent, only one intravenous route (push or infusion) is appropriate at each session. Payers recognize that combination chemotherapy is provided by different routes at the same session.
 
For example, two or more of the following codes may be used to report the use of more than one chemotherapeutic agent: 96408 (chemotherapy administration, intravenous; push technique), 96410, and/or 96414 (... infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump). Modifier -59 should be attached to the lesser-valued technique to indicate that separate agents were administered via different methods.

Coders should be certain that other modifiers do not apply before using modifier -59.
 
For example, modifier -76 (repeat procedure by same physician) can be used by facilities that deliver radiation treatment. If the facility delivers two units of radiation, 77413 (radiation treatment delivery; 6-10 MeV), for example, it can report 77413 twice or 77413 with modifier -76 appended. Modifier -76 should not be used when a procedure is repeated because of an error in the first procedure or to confirm results of the same previous test.