Pathology/Lab Coding Alert

Try your hand at these cases to see if you should use modifier 59

You've learned the principles of modifier 59 (Distinct procedural service); now test yourself with these examples. How you do is important--your carriers are likely watching these codes based on the OIG study.

Case 1: A pathologist extracts a bone marrow aspiration from the left iliac crest and a bone marrow biopsy from the right iliac crest for diagnosis and staging of lymphoma.
 
Modifier 59 or not? Because the physician performed the aspiration and biopsy at different operative sites, Medicare should pay for both extraction services--38220 (Bone marrow; aspiration only) and CPT 38221 (Bone marrow; biopsy, needle or trocar)if you append modifier 59 to 38220.

Opportunity: If a physician had performed the two extractions through the same incision at the same operative session, you should not use modifier 59. But Medicare provides a separate bone-marrow aspiration code that you can report in addition to biopsy code 38221 when you perform the two services together--G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service)--says Beverly Bloedow, coding resource specialist for Hospital Pathology Associates in Minneapolis.

Bottom line: You can use modifier 59 for bone marrow biopsy and aspiration when you have:

1. Different sites, such as contralateral iliac crests, or iliac crest and sternum, or
2. Different incisions on the same iliac crest, or
3. Different patient encounters.

Case 2: A pathologist examines direct smears from pleural fluid (88104, Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation), then concentrates the remaining fluid by cytospin and examines the concentrated smears (88108, Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]).

Modifier 59 or not? Although a "1" allows you to override the 88108/88104 edit pair with modifier 59, you should not do so in this case. The pathologist performs the two services on a single specimen. Medicare's National Correct Coding Policy Manual says that for a single specimen, you should report "only one code from a group of related codes ... that could be performed with the same end result." The manual lists codes 88108/88104 as an example of this principle.