Pathology/Lab Coding Alert

Warning: The OIG says your carrier should crack down on unbundling

When you use modifier 59 (Distinct procedural service) to override the 38220/38221 edit pair, you can be sure your carrier is watching.

Because the Office of Inspector General (OIG) found those code pairs among the most common examples of erroneous 59 billing, you should follow our experts' steps to make sure you use 59 correctly--every time.

In fact, an OIG study found that 40 percent of code pairs billed with modifier 59 did not meet program requirements, and that's why the agency recommends that carriers conduct prepayment and postpayment reviews of modifier 59 use.

You can find the OIG study on the Internet at http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf. 1. Use 59 only when the services are separate and distinct. Using modifier 59 for procedures that are not distinct accounts for 15 percent of misuse, according to the OIG study. That's why you have to understand what constitutes separate, distinct services.

CPT says you may use modifier 59 for two services that "represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury ... not ordinarily encountered or performed on the same day." 

But that definition encompasses some coding do's and don'ts, according to a recent CMS article.

Do use 59 to indicate two or more procedures performed at different anatomic sites or different patient encounters. Different anatomic sites include "different organs or different lesions in the same organ," according to CMS.

Don't use 59 based on the fact that two codes of an edit pair represent different procedures/surgeries--they usually do, CMS says. The edit pair means that you can't report those two different procedures at the same time for the same anatomic site.
 
The OIG study found that coders inappropriately used modifier 59 most often with the NCCI code pair 38221 (Bone marrow; biopsy, needle or trocar) and 38220 (Bone marrow; aspiration only), accounting for nearly 21 percent of the errors caused by reporting two services that were not distinct. Your carriers will be watching these codes, so you need to know when you can and can't unbundle these services.

Read "Quick Quiz: To Unbundle or Not to Unbundle ..." later in this issue for specific coding examples.

Caution: Diagnosis codes won't justify or disqualify you for modifier 59. Just because you have two separate diagnoses from two procedures does not necessarily mean you can use modifier 59, according to CMS. On the other hand, properly using 59 does not require a different diagnosis for each separate CPT code.

You can find the entire CMS article on the Internet at www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf. 2. Know when NOT to use 59.
 
Modifier 59 does not automatically unbundle all National Correct Coding Initiative edits. The [...]