Ophthalmology and Optometry Coding Alert

Question: When is it appropriate to break an NCCI edit with modifier 59?>

Louisiana Subscriber>

Answer: Per CPT^®, modifier 59 (Distinct procedural service) “is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

For example, the physician examines a patient with uncontrolled open-angle glaucoma in the office and performs gonioscopy at the same time. The patient is scheduled for laser trabeculoplasty at the hospital later the same day. During the laser trabeculoplasty, the physician uses a goniolens to help perform the treatment. The National Correct Coding Initiative (NCCI) edits bundle 92020 (Gonioscopy (separate procedure)) with 65855 (Trabeculoplasty by laser surgery). On the claim, you will bill 65855 for the surgery and append modifier 59 to 92020 to bill for the office procedure. This is appropriate because the two procedures were done during different sessions (office and hospital) on the same day. Note that you would not bill for the use of a goniolens during the trabeculoplasty due to the NCCI bundling.

Note: If your payer accepts the X{ESPU} modifiers, report XE (Separate encounter …) instead of 59, as it provides more information about why the unbundling is supported.