Ophthalmology and Optometry Coding Alert

Modifier -59 is to be used for a distinct procedural service. This is something that is distinct or independent from other services performed on the same day, according to CPT. It may be a different session or encounter, a different procedure or surgery, a different site or system, a separate incision, a separate lesion, or a separate injury not ordinarily encountered or performed on the same day by the same physician. And about modifier -59, CPT specifically requires that it be used only if no other modifier is appropriate. For example, if modifier -25 is appropriate, use it and not modifier -59.

The big question is, can you use the -59 modifier to get paid separately for procedures which Medicare normally bundles? The answer, according to Riva Lee Asbell, an ophthalmology compliance consultant based in Philadelphia, is no. You have to use modifier -59 very carefully, and you cant use it to break the CCI [Correct Coding Initiative] bundles, she says. Medicare has bundled those procedures together precisely because, in HCFAs view, they are not distinct or independent. So using the -59 modifier routinely will not help you, and could even hurt you, says Asbell.

Yes, some practices do use the -59 modifier to get paid for separate, but bundled, procedures, says Asbell. Theyll pay you because thats what the -59 modifier is for, she says. But if you get audited, you may be in trouble. Asbell doesnt permit her clients to use the -59 modifier without her sign-off.

Here are some examples of when the -59 modifier would be appropriate, according to Asbell.

1. A patient has an eye exam in the morning. That afternoon, at home, the patient falls and notices blood in her eye. The patient returns to the doctor. That return visit would get the -59 modifier, to show that it is distinct from the earlier visit the same day, says Asbell.

2. A patient is getting reconstructive surgery of the superior and inferior cul-de-sac, both on the right side, due to enophthalmos. You need to use the -59 modifier to differentiate the two different sites, says Asbell, noting that there is no modifier for superior and inferior.

3. A patient is getting basal cell carcinoma repair with a graft on the right lower lid. During the same session, the physician removes a lesion on the cheek. This is a case which would normally be bundled, but which, because there is a separate lesion, does allow for the -59 modifier to get paid for both, says Asbell.

We also spoke to Ginger Hudnall, insurance supervisor for the Southern Eye Institute, about the use of the -59 modifier. We rarely use it, she says. But there is one case when we have used it, when a patient had surgery for cataract and cyclophotocoagulation. The -59 modifier went with the cyclophotocoagulation. The codes would be 66984 (LT or RT) and 66710-59 (LT or RT). The diagnosis for the cyclophotocoagulation must be an appropriate glaucoma diagnosis for a preexisting condition to the cataract surgery.

The -59 modifier is for use under certain circumstances only. These may be, says CPT, a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/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 physician. Bear in mind, however, that modifier -59 should not be used when another modifier is more appropriate.