Ophthalmology and Optometry Coding Alert

Modifier -59 is for procedures you don't normally report together When a patient requires cataract surgery and a vitrectomy in the same session, do you report only one code? If the ophthalmologist repairs a seriously dislocated lens, do you automatically assume there is only one reportable procedure? If you answered "yes" to either of these questions, you may not be taking advantage of all situations in which you can use modifiers -59 and -51. Read on for more information on these modifiers, which may be helpful when you report related codes on the same claim. Modifier -59 Works When Codes Are Close Ophthalmology coders use modifier -59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date. In general, coders append modifier -59 to procedure codes when the physician:

sees a patient during a different session
treats a different site or organ system
sees a patient during a different encounter
treats a different organ system
treats a separate injury. Modifier -59 is "used when multiple procedures in the same (code areas) are performed at the same time," says Linda Parks, MA, CPC, CMC, CCP, coding specialist in Marietta, Ga.

Example: Apatient with a previously diagnosed vitreous prolapse reports to the ophthalmologist for cataract surgery. During the session, the physician performs cataract surgery and a vitrectomy. You should: report 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one-stage procedure], manual or mechanical technique [e.g., irrigation and aspiration or phacoemulsification]) for the cataract removal.
attach modifier -59 to 67010 (Removal of vitreous, anterior approach [open sky technique or limbal incision]; subtotal removal with mechanical vitrectomy) to represent the vitrectomy. Why? The modifier shows the carrier that the vitrectomy was a separate problem from the cataract removal, and not incidental to the cataract procedure. Remember: The higher the relative value units (RVUs) for a given code, the more you'll be paid for the procedure. Always attach modifier -59 to the code with the lower RVUs. Not Sure? Check NCCI If you're stuck on whether you should bill codes with modifier -59, check the National Correct Coding Initiative (NCCI) edits, Parks says. If the codes you are reporting have indicators of "1" next to them, this means you can append the modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.

Time-saver: Increase your modifier -59 reimbursement rate by using -59 only when absolutely necessary, experts say. Many private payers do not require a modifier for multiple-procedure scenarios or don't recognize -59 [...]