Orthopedic Coding Alert

Modifiers -59 (Distinct procedural service) and -51 (Multiple procedures) have similar applications: to show the insurer that you performed medically necessary services that aren't usually billed together. The problem is that many coders and carriers have trouble choosing which modifier is appropriate for certain services. Knowing that modifier -59 is most often used to report services not normally billed together can help you determine when it should be assigned. Modifier -59:The Unbundler? According to CPT, modifier -59 is used in any of five situations: different sessions or encounters, different sites or organ systems, separate incisions/excisions, separate lesions, or separate injuries (or areas of injury). Tammy Boyer, CPC, coding and compliance administrator at Orthopedics and Sports Medicine, an orthopedic practice in Burlington, Iowa, refers to her CCI listing to determine whether modifier -59 should be added to a procedure code. "If the procedures I want to code together are considered bundled, and the code I want to use has a '1' by it, I use modifier -59 with the code, as long as one of the five situations [listed above] is taking place."

For instance, Boyer says, modifier -59 is appropriate when a patient undergoes a medial meniscectomy (29881) and lateral femoral condyle chondroplasty (29877). "The chondroplasty is considered bundled into the meniscecto-my, but because it was done in a different compartment, I append modifier -59 to it, and the claim gets paid." Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code. Note that only CCI edits with a status indicator of "1" may be unbundled using modifier -59. Those code combinations with a status indicator of "0" may not be unbundled under any circumstances. You do not need to append modifier -59 if CCI does not bundle the multiple procedure codes you are billing for the same patient on the same day. Modifier -59 should not lead to a reduction in reimbursement. Do not reduce your fees when billing, and appeal if the payer reduces your modifier -59 claims.

Keep in mind that modifier -59 should not be used indiscriminately to increase payments or protest CCI coding edits. Because of its ability to unbundle CCI edits and increase payments, payers may give modifier -59 special scrutiny. Therefore, always keep thorough notes available to substantiate its use. According to the July 1999 CPT Assistant, " CPT guidelines clearly indicate that the -59 modifier is only used if no more descriptive modifier is available and the use of the modifier -59 best explains the circumstances." Modifier -51 Will Cut Your Fee CPT states, "When multiple procedures, other than E/M services, are performed at [...]