Pathology/Lab Coding Alert

Look to 91 or 76 in some cases.

Rumor has it that Medicare no longer accepts modifier 59 (Distinct procedural service), sending lots of coders scrambling for an alternative. But don’t believe everything you hear.

Reality: You can still use modifier 59 when you need to demonstrate that your pathologist performed procedures on two different specimens, particularly to override a Correct Coding Initiative (CCI) edit pair.

Not for repeat: What you can’t continue to do, however, is use this modifier for repeat procedures or other instances when a different modifier would be more appropriate.

Find the Rumor’s Source

Many Part B MACs posted instructions about modifier 59 on their websites earlier this year, which may have created the confusion. Cahaba GBA, for instance, a Part B payer, stated, “Modifier 59 can only be used, when medically necessary, to unbundle a procedure code that has been bundled related to the NCCI.”

Or there’s this from Noridian: “Per a system-process change …, modifier 59 is no longer considered a valid repeat modifier. Procedures billed with modifier 59 will be denied as exact duplicates. To avoid these denials on repeat procedures, you may bill using a 76 (Repeat Procedure by Same Physician) or 91 (Repeat Clinical Diagnostic Laboratory Test to Obtain Multiple Results) modifier, whichever is most appropriate.

Solve the Dilemma

You might typically bill multiple units of a pathology code using units, such as 88305 x 3 for three distinct skin lesion exams (88305, Level IV - Surgical pathology, gross and microscopic examination, Skin, other than cyst/tag/debridement/plastic repair), and that won’t run afoul of the new policy.

Problem: But some payers have directed coders to list each 88305 on a separate claim line with modifier 59 on the second and subsequent codes. Under the new policy stated by Cahaba, Noridian, and other Medicare payers, using modifier 59 in this way for multiple units is a problem.

Solution: Choose the proper modifier such as 76 or 91, as Noridian recommends. In a case like the preceding example involving multiple units of a pathology exam on distinct specimens, modifier 76 is more appropriate.

You should reserve modifier 91 for clinical diagnostic lab tests, not for pathology physician services. Also, you should use modifier 91 only when a physician requests multiple tests for diagnostic purposes, not when the lab repeats a test due to technical or quality assurance issues.

Put 59 Instruction in CCI Context

So what about using modifier 59 to override CCI edits, as you’re used to doing, and as the Cahaba notice mentioned?

You can continue to use modifier 59 in that context. When a CCI edit pair shows a modifier indicator of “1,” you may use a modifier, where appropriate, but when the edit pair shows modifier indicator of “0,” you can never use a modifier, even if appropriate, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group in Florida.

59 not only choice: Although you can continue to use modifier 59 in this context, you won’t necessarily always choose that modifier. CCI instruction has always indicated that when it’s allowed and appropriate to override a CCI edit pair, you should use modifier 59 or another suitable modifier.

In fact, Medicare recently added modifiers to the list of those you can use to override CCI edits, including 24 (Unrelated evaluation and management service by the same physician during a postoperative period) and 57 (Decision for surgery).

Although 59 has often been the main modifier used to bypass CCI edits, having other modifier choices is good news because it makes your reporting more granular, says Laureen Jandroep, CPC, CPC-I, CMSCS, CHCI, senior instructor at CodingCertification.org in Oceanville, NJ.

Bottom line: Continue to choose modifier 59 or another appropriate modifier to override pathology codes subject to CCI edits, but stop using modifier 59 for repeat services. Choose 91 or 76 instead, or report the codes on a single line showing multiple units. Contact your Medicare contractor for instructions specific to your region.