Orthopedic Coding Alert

The OIG plans to crack down on -59 usage in 2005, so be careful

If you think of modifier -59 as an easy way to collect when you bill bundled procedures together, you may gain extra reimbursement for your claims, but you could be asking for trouble. To avoid running afoul of CMS regulators, always be sure the surgeon's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59 (Distinct procedural service).
 
Although several modifiers allow practices to unbundle National Correct Coding Initiative (NCCI) edits, orthopedic practices most often choose modifier -59 in order to separate code pairs. But in its recently released 2005 Work Plan, the Office of Inspector General (OIG) at the Department of Health and Human Services stated that it intends to scrutinize claims that include modifiers used to bypass NCCI edits. Therefore, it's more important than ever before to ensure that you're using modifier -59 appropriately. Follow our experts' advice to determine when you should - and should not - append modifier -59 to your claims.

If Other Modifiers Will Do the Job, Avoid -59

You should never use modifier -59 if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant.
 
In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.
 
Note: See our Modifier -59 decision tool on page 93 to help you determine when you should select modifier -59 rather than other modifiers.
 
Coding example: The orthopedic surgeon attempts a percutaneous fracture fixation (26727, Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each) on a patient's left third finger but cannot complete the procedure. He converts to an open procedure and performs an open finger shaft fracture treatment (26735, Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without internal or external fixation, each).
 
What NOT to do: The NCCI bundles 26727 into 26735, but the edit contains a "1" modifier, which means you can separate the code pair if the physician documents two separate and distinct procedures, and you append a modifier. But in this case, because the physician converted a percutaneous procedure to an open one on the same finger, you are not justified in reporting both codes and appending modifier -59.

Finger Modifiers Trump -59, When Accepted

Caveat: If, however, the physician performs an open procedure on the patient's third finger and a percutaneous procedure on the patient's fourth finger, you should append modifier -F2 (Left hand, third digit) to 26735, and append modifier -F3 (Left hand, fourth digit) to 26727. Because NCCI 10.3 lists the finger modifiers (-FA, -F1 to -F9) as acceptable to use when separating code pairs, you should use them instead of modifier -59 in this case. In some cases, however, your payer may not accept "F" codes - in that circumstance, you should report modifier -59 instead.

Don't Unbundle Without Cause

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and if no more appropriate modifier exists.
 
For example: The surgeon performs a lumbar decompressive laminectomy at L3 for spinal stenosis (63047, Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) followed by a lumbar microdiskectomy at L4-L5 for disk herniation (63030, Laminotomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]).
 
Correct Coding: In this case, the orthopedic surgeon performs the decompression and microdiskectomy at different spinal levels, and each procedure is associated with a different diagnosis. Because of the distinct nature of these procedures, you may correctly report 63030-59 and 63047. Your supporting documentation should stress that the decompression and diskectomy occurred at separate anatomic locations.

Make Sure -51 Isn't More Appropriate

"We use modifier -59 if - and only if - we perform two procedures that are typically bundled in the NCCI edits," says Elisabeth P. Fulton, CPC, coding and auditing department supervisor at Orthopedic Specialists of the Carolinas in Winston-Salem, N.C. "If the two codes appear to the insurance company that they are bundled, but should be paid because they are separately identifiable procedures, we would append the -59 modifier to the second code to correctly bypass the edit."
 
If NCCI doesn't bundle, don't use -59: "If the two procedures are not bundled, the -51 modifier (Multiple procedures) is more appropriate," Fulton says.

Payers Are Watching

Some insurers have grown so suspicious of modifier -59 misuse that several payers, such as the North Dakota Medicaid program, handle modifier -59 claims by hand. If the computer detects modifier -59 on a claim, someone will manually process the claim before Medicaid will reimburse the practice.