Pathology/Lab Coding Alert

Correctly using modifier -59 (distinct procedural service) can help prevent denials for multiple procedures performed on a single patient on the same day.

Pathologists often carry out such multiple procedures, and each procedure should be coded individually. In fact, the CPT manual states, It is appropriate to designate multiple procedures that are rendered on the same date by separate entries. Unfortunately, doing so may appear to contradict the Health Care Finance Administrations (HCFA) Correct Coding Initiative (CCI) rules, leading to a denial of one or both of the claims.

Correct Modifier Usage Key

The correct use of modifiers is the solution to this problem, says Dari Bonner, CPC, CPC-H, CCS-P, compliance specialist and president of Xact Coding and Reimbursement, Inc., in Port St. Lucie, Fla. Specifically, modifier -59 would be used to indicate that a service is distinct and independent from any other service performed on the same patient, on the same day, by the same pathologist, she continues.

According to CPT, the circumstances that may warrant the use of modifier -59 involve procedures that are not normally reported together, but represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. CPT also notes that -59 should only be used if no more descriptive modifier is available.

Accurate use of modifier -59 requires a knowledge of which codes normally cannot be listed together based on Correct Coding Edits published in the National Correct Coding Policy Manual for Part B Medicare Carriers. These edits list code pairs that are excluded based on two relationships:

1. one code is comprehensive and includes the
service of the other, component code; or
2. the two codes are mutually exclusive, such as two different lab tests that measure the same factor.

Within the list of code pairs in the Correct Coding Edits, you will notice the use of superscript numbers 0 or 1 on some codes, says Bonner. A 0 means that a modifier would not be appropriate for that code pair under any circumstances. A 1 means that a modifier is allowed, if appropriate, she continues. In fact, Medicare requires the use of a modifier for any of these code pairs on which it is allowed if the same physician reports them together for the same patient, on the same day.

Comprehensive and Component Codes

Although coders must check the current version of Correct Coding Edits to get a complete list of excluded code pairs, many of the comprehensive and component [...]