Otolaryngology Coding Alert

Question: We reported 99212 with an injection code, and appended modifier 59 to the claim, but the payer only provided reimbursement for the injection — not the E/M code. What went wrong?

North Carolina Subscriber

Answer: You should never use modifier 59 (Distinct procedural service) on an E/M service. Scenarios like this require the use of modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery), depending on encounter specifics.

In general, modifier 25 should be used on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period such as an injection; while procedures with a 90-day global period will typically take modifier 57.

Keep in mind: Even in situations when you are reporting two procedures together and not an E/M service, modifier 59 might not be your best option. Modifier 59 should be considered the modifier of last resort, and modifiers for specific anatomic sites, for example, may be more appropriate under the right circumstances, such as modifiers RT (Right side) or LT (Left side).

Additionally, while all Medicare Part B carriers recognize the “X” modifiers, private payers have been slow to adopt them; so, depending on the payer, you may have the option to use an X modifier from the following:

• XE (Separate encounter …), which you can use for multiple encounters on the same date;
• XS (Separate structure …), which you can use when the same procedure is performed on different structures;
• XP (Separate practitioner …), which you can use when different practitioners perform the same procedure; and
• XU (Unusual Non-Overlapping Service …), which you can use when your physician performs different services on the same structure or anatomical site that involve distinct components.

These modifiers tell the payer why you feel the need to unbundle the services you are submitting. But in order to use these codes, it is important to understand the payer, so find out what they want you to retain or submit to justify using these modifiers.