Ophthalmology and Optometry Coding Alert

If you always apply modifier 59 and unbundle two procedures that the Correct Coding Initiative (CCI) bundles when a physician performs them during the same session but for different reasons, you had better rethink your modifier use.

You can apply modifier 59 (Distinct procedural service) only if the two procedures were in different sessions, were in different anatomical areas or were otherwise totally unrelated.

The bottom line: Missing the mark on modifier 59 is sure to get you in trouble with auditors.

Many providers and coders believe that they can use modifier 59 as long as they have different diagnoses or reasons for the procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City. This is a no-no, and the HHS Office of Inspector General (OIG) has warned about this sort of inappropriate overuse.

Why: Medicare could save $538 million by reducing improper use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and $59 million by cutting back on the inappropriate use of modifier 59, the HHS Office of Inspector General says in its 2007 compendium of unimplemented recommendations.

What it means to you: Expect your carriers to be scrutinizing your modifier 25 and 59 claims and requesting documentation to support proper modifier use.

CPT's modifier 59 guidelines say that if another modifier is appropriate, such as if it defines the site of the procedure better, you should use it instead of modifier 59, Cobuzzi says. For example, you should use modifiers LT (Left side) and RT (Right side) to indicate anatomical location.

Unfortunately, many payers, including some Medicare carriers, have a hard time recognizing these modifiers. So you may end up having to use modifier 59 after all with those carriers. Similarly, Medicare is supposed to pay for multiple units of lesion removal codes, but with some carriers you may have to bill the same code multiple times using modifier 59 instead.

Bottom line: You may use modifier 59 for two separate sessions during which the physician provides services that are normally bundled when done in a single patient encounter, Cobuzzi says.