Otolaryngology Coding Alert

Modifier -59 Keeps Your Related Code Claims Clear

Published on Wed Sep 08, 2004

Append -59 when you can show a necessary separate service

When a patient reports for a nebulizer treatment and instructions on the same day, do you report only one code?

If you answered "yes," you may not be taking advantage of the situations when you can use modifier -59 (Distinct procedural service). Here's what our coding specialists say you should do to report related codes on the same claim.

Modifier -59 Works When Codes Are Close

Allergy coders use modifier -59 to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.

Think of it this way: Modifier -59 tells the payer that the procedures were not components of one another but were both medically necessary and separate from one another, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Beware: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary. If you overuse this modifier, you may indicate routine unbundling of services to insurers, and they can initiate a review based on this suspicion, coding experts say. Your documentation must clearly identify the medical necessity and separateness of the unbundled service.

Asthma Visits Offer -59 Opportunities

A common modifier -59 scenario in allergy practices involves patients who receive nebulizer treatments and instructions on the same day.

Example: A 5-year-old established patient newly diagnosed with asthma reports with still-worsening symptoms and needs to be checked for medication adjustments. The allergist performs a level-three E/M service, administers a nebulizer treatment and then decides that home treatments are necessary for the patient.

He instructs the patient and his parents about how to conduct home nebulizer treatments before sending the child home. The claim should read:

99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity.

If your insurance company requires it, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 to show that the E/M service was separate from the nebulizer treatment and instruction.

94640 - Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing [IPPB] device).

94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) with modifier -59 attached. You should report 94664 when the medical staff evaluates and educates a patient on the correct use of a metered dose inhaler (MDI) or nebulizer, adds Mary Beth Wass, MC, CMM, manager at the Asthma and Allergy Center in Papillion, Neb.

ICD-9 code 493.02 (Extrinsic asthma; with [acute] exacerbation) should cover the entire service, says Lee Ann Shumiloff, billing manager at the West Virginia University School of Medicine in Morgantown. She also reminds coders that you should attach modifier -59 to the code for the additional procedure performed.

Give Your Payer a Call First

Check with your individual payers to see if modifier -59 is necessary when reporting multiple minor procedure claims. For instance, the above reporting method "works well with some carriers, but not all of them, of course," Shumiloff says. However, don't be afraid to use it when no other modifier seems appropriate, says Catherine A. Hudson, RMA, RPT, with a physician practice in Marietta, Ga.

"Using the -59 modifier when reporting multiple procedures has gotten [our office] payment when any other way [of reporting] could not - especially with Medicaid," Hudson says.

Field-tested tip: "If the payer denies our claim, we send a request for review to the carrier with copies of the pulmonary function report along with our metered dose inhaler training check-off sheet," Wass says.

If you're not sure whether you should bill codes with modifier -59, check the National Correct Coding Initiative edits. If the codes you are reporting have indicators of "1" next to them, you can append the modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.