Ophthalmology and Optometry Coding Alert

Don't be one of the 40 percent of claimants who misuse the modifier

An ophthalmologist in your practice excises a lesion on one eyelid and biopsies a lesion on another eyelid. You report 11440-59 and 11100--and receive a denial from the carrier. Sound familiar?

You're not alone. A November 2005 HHS Office of Inspector General study found a 40 percent error rate in the use of modifier 59 (Distinct procedural service) in its sample of claims, resulting in $59 million in improper payments in 2003. As a result, the OIG is encouraging CMS' Part B carriers and Recovery Audit Contractors to scrutinize your claims that use this modifier, and you can expect to see a lot more pre- and postpayment audits in 2006. To protect your claims, use these strategies.

Confirm Separate Region Before Using 59

Pull a sample of your modifier 59 submissions and verify that those claims properly represent distinct procedural services. Fifteen percent of OIG's audited claims using modifier 59 had procedures that weren't distinct because "they were performed at the same session, same anatomical site, and/or through the same incision," says Daniel R. Levinson, inspector general, in "Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits."

Make sure the physician is working in a separate body area or has made a separate incision before you use modifier 59, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash.
 
Here's how: Suppose you pull an eyelid surgery claim that contains modifier 59 on 11440 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) and 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion).

The National Correct Coding Initiative (NCCI) edits show 11440 as the column 1 or comprehensive code and 11100 as the column 2 or component code. This bundle makes the biopsy (11100) a component of the destruction (excision), unless "the procedures are performed on separate lesions or at separate patient encounters," according to the CMS in "Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service."

Documentation included in the notes shows that the ophthalmologist biopsied and destroyed different lesions, so your claim meets the first test. Your next step is to check to be sure:

• you appended modifier 59 to 11100 (the component or column 2 code), not to 11440 (the comprehensive or column 1 code)
 
• you linked the procedures to appropriate diagnoses, such as 11440 to 702.0 (Actinic keratosis) and 11100 to 172.1 (Malignant melanoma of skin; eyelid, including canthus).

Append 59 to the Secondary Code

Although appending the modifier to the column 2 code may seem elementary, the OIG's study found numerous application errors: 11 percent of claims had modifier 59 appended to the primary code instead of the secondary code, and another 13 percent had modifier 59 appended to both the primary and secondary codes.

Action: "If you notice that you have put modifier 59 on the wrong code, resubmit the claim," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

You can further clarify the anatomic site by adding a second modifier: RT (Right side), LT (Left side), E1 (Upper left, eyelid), E2 (Lower left, eyelid), E3 (Upper right, eyelid) or E4 (Lower right, eyelid), says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

"You are not limited to using modifier 59 by itself--and by all means, the secondary modifier will paint a clearer picture of what actually happened," she says. Append modifier 59 first followed by the appropriate anatomic modifier (for example: 11100-59-RT).

Note: To read the OIG's modifier 59 report, visit http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf.

You can test your modifier 59 skills with examples from the CMS "Modifier 59 Article" at www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf.