Ophthalmology and Optometry Coding Alert

Trying to bypass CCI edits? Append modifier 59 to the wrong code and you can kiss your reimbursement goodbye.

Medicare payers are taking a new, firmer stance on modifier 59 use. Highmark Medicare, a Part B payer in four states, issued a strongly-worded alert in August reminding you to keep a close eye on those Correct Coding Initiative (CCI) edits.

What you already know: Medicare rules state that you can report staged procedures following a related procedure by appending a modifier, such as 58 (Staged or related procedure or service by the same physician during the postoperative period).

However, unbundling related services reported on the same date of service, when appropriate, may require you to append modifier 59 (Distinct procedural service) to the bundled code.

What you may not know: You cannot append modifier 59 to separate every CCI bundle. When another modifier (such as RT, LT or 58) is more appropriate, they should be the first modifier of choice. Some payers may want to see both RT/LT and 59.

Plus: Some practices have been appending the modifier to the primary procedure code, rather than the secondary procedure. But to code properly, you should append the modifier to "the secondary, additional, or lesser procedure(s) or service(s)" according to Highmark's missive.

Don't forget: CCI denotes the "lesser" procedure by placing it in column II of the CCI edits list. "The RVUs associated with the code are not necessarily the indicator of which is a column I or column II code, because a column II code can carry a higher RVU value than the column I code," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

"When ... the 59 modifier is improperly reported with the column I rather than the column II code, the edit will not be bypassed and the column II code will be denied," Highmark notes in its alert.