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 edits have a column that notes with a "1" or "0" whether a modifier is "allowed" or "not allowed." You're in the clear to unbundle the separate and distinct procedures if the edits list a "1"--but you're out of luck if you try to do this when you see a "0."

Next step: Don't put in modifier 59 on autopilot when you see a "1." The edits don't specify which modifier to use, or if a modifier even qualifies for your situation, says Denise Paige, CPC, past president of the American Academy of Professional Coders' Long Beach Chapter in California. 

3. Append 59 to the correct code in the bundle.

If you think it doesn't matter which code you append with the modifier, think again. The OIG has instructed CMS to "... ensure that the carriers' claims processing systems only pay claims with modifier 59 when the modifier is billed to the correct code."

Do this: You should always put the modifier on the column 2 code, says Rick Gawenda, PT, at Detroit Receiving Hospital.

The OIG study clarified this point by stating that the column 2 code is always the secondary service, and that, according to CMS, you should always attach modifier 59 to the secondary code--the second code of the code pair. Indeed, the NCCI frequently asked questions direct you to "append modifier 59 to the column 2 code" and explains that Medicare will pay the column 1 code but not the column 2 code.

You can find these questions on the Internet at http://www.cms.hhs.gov/NationalCorrectCodInitEd/, select FAQ.

Clarify confusion: For column 1/column 2 edit pairs, the comprehensive code is in column 1, while the lesser-valued code is in column 2. Because mutually exclusive edit pairs list the lesser-valued service in column 1, some coding experts have advised appending modifier 59 to the column 1 code for mutually exclusive edits.

CMS instruction may have lent itself to this interpretation, stating that, "The secondary, additional, or lesser procedure(s) or service(s) must be identified by adding the modifier '59,' " and "the '59' modifier ... should be attached to the lesser valued technique" (Medicare Claims Processing Manual, chapter 23, section 20.9).

Don't miss: But the latest instruction from the OIG report and the CMS article confirm that you should always append modifier 59 to the column 2 code--whether it is for column 1/column 2 or mutually exclusive edit pairs. That means if you don't override mutually exclusive edits with modifier 59, the payable code is the one with the lesser value.

4. Include documentation to argue your case.

Lack of documentation accounts for 25 percent of erroneously billed modifier 59 claims, according to the OIG study. That's why you must document the criteria for using 59--that the service is distinct from other procedures on the same day. Your documentation should show either a different anatomic site or a different patient encounter to justify using modifier 59.
 
Fortunately, good documentation doesn't mean a novel's worth of extra notes. Along with the usual documentation, the physician should record the time of day he did the procedure and use words like "after" or "followed by," Gawenda says. Or mention the separate sites if it applies.

Tip: If you code for a multispecialty practice, check for patients who've had multiple treatments the same day, because the procedures could be bundled.

5. Audit your practice's 59 use--before your carrier audits you.

You may think your claims are A-OK if you're following NCCI and Medicare guidelines, but it never hurts to see your stats. Without a self-audit, you may not realize that your modifier 59 use is above average. And these high numbers will wave a red flag at your carrier--especially after the latest OIG report.

Best bet: Keep track of how often your practice unbundles codes with modifier 59, and review the stats every quarter. If you find that you're appending 59 a bit loosely, meet with your colleagues and discuss possible reasons for the high use.

Final word: Don't get confused by the different versions of NCCI edits. The NCCI usually comes out with new edits every quarter, but remember that private practices are always one NCCI version ahead of all other settings, Gawenda says. This means that hospital settings will use NCCI version 12.0 until July 1 before adhering to NCCI 12.1. Private practices should have been using NCCI 12.1 since April 1.