Optometry Coding & Billing Alert

Question: Should I always append modifier 59 to the lower-valued code of an NCCI bundle?


Washington Subscriber

Answer: This can be a confusing point, and it has led to conflicting advice in the past. In most cases, you append modifier 59 (Distinct procedural service) to the lower-valued code, but that's not always the case. A better rule to follow is this: Append modifier 59 to the column two code or the component code of a code pair edit.

The National Correct Coding Initiative list of mutually exclusive codes contains edits consisting of two codes (procedures) that a physician cannot reasonably perform together based on the code definitions or anatomic considerations. Each edit consists of a column one (comprehensive) and column two (component) code. If you report both codes on the same service date for one beneficiary without an appropriate modifier, Medicare will pay only the comprehensive code.

When clinical circumstances justify appending a modifier to the column two code of a code pair edit, the carrier may allow payment of both codes.

Example: An optometrist is following a patient with different chronic conditions. He performs SCODI (92135, Scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) to check on the progression of glaucoma and fundus photography (92250) to track changes in the patient's diabetic retinopathy.

Code 92135 is the comprehensive (column one) code and 92250 is the component (column two) code. Because the optometrist is following two different diagnoses, clinical circumstances may allow you to report both codes. You should attach modifier 59 to the component/column two code: 92250.

Problem averted: Understanding the mutually exclusive tables will help you avoid incorrect modifier use. If you based modifier attachment on the codes- values instead of the codes- column designations, you would incorrectly attach modifier 59 to 92135 -- the lower-valued code. (The 2006 National Physician Fee Schedule assigns 1.16 relative value units to 92135 and 1.99 RVUs to 92250.) You should instead append modifier 59 to 92250 -- the component and, incidentally, higher-valued, code. Report 92250-59.

Advice for Reader Questions and You Be the Expert contributed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas; and Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.