Indicators, separate sites hold clues to proper use. The problem: Tip 1: Know When to Use Modifier 59 The Office of Inspector General (OIG) and many payers, including Medicare, continually review physicians' modifier 59 use. In fact, according to a 2005 review by the OIG and an independent contractor, 40 percent of code pairs studied did not meet program requirements for proper modifier 59 use. There are circumstances when you can -- and should -- use modifier 59, however. For instance, you may use modifier 59 to identify procedures that are distinctly separate from another procedure provided by your physician on the same day. In addition, you may append 59 to your claim when your physician: • sees a patient during a different session on the same day; • treats a different site or organ system; • makes a separate incision/excision; • tends to a different lesion; or • treats a separate injury. This all boils down to two key questions: Is the second procedure (which is normally bundled with the first procedure) performed at a different site than the first service? Or, secondly, was it done during a separate encounter on the same day? Example: The two procedures are considered bundled, with 66984 being a column 2 code to 66982. You can correctly unbundle the services as follows: • 66982-LT (Left side) • 66984-59-RT (Right side). Important: Tip 2: CCI Limits Codes You Can Report Separately You should always check the Correct Coding Initiative (CCI) edits to determine if two or more procedures are bundled. The CCI edits are updated quarterly and new additions and deletions may have occurred which may change your billing circumstances. The CCI edits may list two codes as "mutually exclusive" of one another or pair them together ("bundle" them). If you see reference to "column 1" and "column 2" codes, CCI bundles the procedures and normally you would not report them together except when it is appropriate to do so. Unbundling is not automatic: Why: A modifier indicator of "0" means that you may not unbundle the edit combination under any circumstances. Alternately, a "1" indicator opens the possibility for you to override an edit using a modifier if your documentation supports that the procedures are distinct from one another and meets the criteria described in the definition of modifier 59. Example: CCI bundles 92135 and 92250 as mutually exclusive with a "1" modifier indicator, which indicates you may separately report them, when appropriate, using modifier 59. Therefore, when the ophthalmologist performs the services on different eyes, report both services with modifier 59 appended to the column 2 code (92135): • 92250-LT • 92135-59-RT. Clear documentation is essential in the event of a payer review, cautions Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. Tip 3: Always Prove Necessity With Documentation When you're trying to decide whether you should append modifier 59, use a logical approach. Ask: Did the second procedure require a separate approach or was it performed on a separate anatomical site? Although modifier 59 is on the OIG watch list, there is less risk of overusing it if it's well-supported, says Rena Hall, CPC, billing/insurance specialist of the Kansas City Neurosurgery Group in Missouri. Important: Never use modifier 59 just to get paid for a procedure. "Make sure there is well-documented support for a separate and distinct procedure meeting the criteria for unbundling and appending modifier 59," Hall points out. In addition, CPT instructions dictate that if a more specific modifier describes the situation, you should not use modifier 59. Because the modifier has the potential to bypass CCI edits, coders use this modifier too often, confirms Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of surgery and anesthesiology. Modifier 59 "should be the modifier of last resort and used only when the procedure was clearly distinct and different from that of the other procedure," she adds.