Otolaryngology Coding Alert

Typically, modifier -59 is used to identify a procedure that would be considered bundled into other services rendered on the same date. But because of special circumstances, the surgeon is requesting separate payment. The use of modifier -59 (distinct procedural service) can be dangerous for otolaryngology practices.

According to CPT 1999, this may represent a 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. However, when another already established modifier is appropriate, it should be used rather than modifier -59. Only if no more descriptive modifier is available, and modifier -59 best explains the circumstances, should modifier -59 be used.

The effect of adding the -59 modifier to the secondary procedure when filing a claim is to unbundle the two procedures in the global period, overriding the automatic edits of private payers and Medicares Correct Coding Initiative (CCI) edits.

Because of its unbundling capability, however, modifier -59 also can be a red flag for medical review; if used incorrectly or too frequently, it could lead to an audit, says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, NJ.

Different Times or Different Sites

We dont use -59 often, but there are circumstances where it makes all the difference, says Stella Almassian, the administrator of the Department of Otolaryngology at Northwestern University in Chicago, IL. For example, we recently had a patient who came in for epistaxis. Cauterization was performed, but the patient returned several hours later, again bleeding profusely, so the physician performed posterior packing. The carrier would likely have denied one of the claims because these were similar procedures performed on the same day. So we added modifier -59 for the second packing. After all, it was a completely different procedure, and it was done several hours later on the same day.

Procedures performed on separate sites on the body also may be billed using modifier -59, says Gretchen Segado, CPC, assistant compliance officer at Thomas Jefferson University in Philadelphia, PA. Say a patient has a radical neck dissection, 41155 (glossectomy; less than one-half tongue; composite procedure with resection floor of mouth, mandibular resection and radical neck dissection [Commando type]) on one side of the neck, and also a cervical lymphadenectomy, (38720, complete) on the other side. The CCI has an edit that says 38720 is a component of 41155, so if you dont use modifier -59, your claim for the 38720 will be edited out, Segado says.

Almassian cites a similar case: Our department treated a patient with a lymph node on one side of the neck and a carcinoma on the other side, so we performed two separate neck proceduresa thyroidectomy and neck dissection for cancer on one side, and a neck dissection on the other side. We billed the first neck dissection as a multiple procedure, but the claim was denied by the insurance company, which maintained it should have been bundled to neck dissection on the other side. Then we claimed the procedure with modifier -59 in an appeal, and they paid it. Of course, we included a letter documenting our procedures.

Two Key Questions

If the procedure in question could potentially be bundled, when determining whether your ENT claim should include modifier -59, you need to ask the following questions:

1. Is there a separate operative note that indicates the procedures took place at different times during the day?

2. Were the procedures performed on different sites of the body, or was one procedure performed just to provide
access for or to facilitate the primary procedure?

If the procedures took place at different times, or were performed on different sites of the body, modifier -59 may be appropriate. If, on the other hand, the secondary procedure was performed simply to facilitate the primary procedure, you should not use modifier -59.

It is important to remember that the amount of time spent on a procedure does not, in itself, permit the use of the -59 modifier.

Cobuzzi adds that many payers, including Medicare, are bundling some procedures strangely. Commercial carriers, for their part, may arbitrarily decide to change or apply Medicare guidelines. And some practices have responded to such repeated irrational bundling by looking for other ways to get reimbursed for the procedures they perform.

Contacting the carriers medical director can be helpful, but Cobuzzi says getting through can be nearly impossible.

If a carrier rejects a claim because procedures were kept bundled and instructs you to use modifier -59, it helps to get that instruction in writing; otherwise, if the claims are later audited, the practice could be accused of fraud. Unfortunately, Cobuzzi says, there is little chance such written instructions will be forthcoming.