Pediatric Coding Alert

There’s more to separating services than using modifier 59.

Whenever your pediatrician performs more than one different service on the same date of service (DOS), there’s a good chance you’ll need to reach for a modifier to notify your payer that the services were separate and distinct.

But simply reaching for modifier 59 (Distinct procedural service) isn’t the correct way to do this. Sometimes, other modifiers may be more appropriate. Here’s how to make that determination.

First, Understand NCCI PTP Edit Pairs

Most times, services that are performed together on the same date do not present a problem, and no modifier is needed when they are reported together. Sometimes, however, multiple same-day services need to be unbundled, and in those cases you will need to either document medical necessity and append the appropriate modifier or understand National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and append an NCCI-associated modifier.

Here’s how NCCI PTP edit pairs work: The Centers for Medicare & Medicaid Services (CMS) regards one service as being component to another service, which CMS calls the comprehensive service. CMS creates pairs of services based on this relationship, then assigns Column 1 status to the comprehensive service and Column 2 status to a code they regard as being a component part of the Column 1 service.

CMS then assigns modifier indicators to each edit pair:

• An indicator of 0 means that the pair cannot be unbundled with an NCCI-associated modifier and that only Column 1 procedures will be paid in claims featuring both services.
• An indicator of 1 means that both services may be reported together if an NCCI-associated modifier is appended to the Column 2 code and both services are eligible for payment.

Example: CMS regards immunization administration codes 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered …) and +90461 (… each additional vaccine or toxoid component administered …) as comprehensive services that include sick visit codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) as component services. So, 99202-99215 are bundled into the 90460/+90461 services, and the codes are considered an edit pair with a modifier indicator of 1.

This means you must append an NCCI-associated modifier to the column 2 code, which leads us to the next unbundling determination.

Then Understand Medical Necessity to Unbundle E/Ms from Procedures

Another reason for using a modifier to unbundle services with the same DOS involves medical necessity. And nowhere is that more evident than in the above example, where the office/ outpatient evaluation and management (E/M) needs to be justified in addition to the procedure.

In this case, if the provider’s documentation indicates the E/M is separately identifiable from the procedure, you’ll use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the 99202-99215 to show the E/M was both separate and significant.

Get Familiar With Appropriate Modifiers

CMS provides an exhaustive list of NCCI-associated modifiers. While these are the only modifiers you can use to unbundle NCCI PTP edit pairs, they also form a useful list of alternatives to modifier 59 for most other unbundling scenarios:

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79 Other modifiers: 27, 59, 91, XE, XS, XP, XU

Other modifiers: 27, 59, 91, XE, XS, XP, XU (www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-faqs)

Here a few examples you can use to determine correct modifier use.

Anatomic modifier example: Your provider performs a lengthy cautery using a silver nitrate stick on both the left and right nostrils of a patient with a history of nosebleeds. You report the service with 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/ or packing) any method). As the procedure does not specify whether the service is unilateral or bilateral, you will need to use an anatomic modifier to help your payer see the medical necessity of performing the procedure on both nostrils. In this case, you can append modifier 50 (Bilateral procedure) or LT (Left side) and RT (Right side) in these circumstances depending on payer preference.

Global surgery modifier example: Your pediatrician performs an office/outpatient E/M on a patient who tripped and fell, injuring their left shoulder. The pediatrician then performs a closed treatment of a non-displaced left sternal end clavicle fracture on the patient, reported with 23500 (Closed treatment of clavicular fracture; without manipulation).

Again, like the earlier E/M unbundling example, you still need to show medical necessity for performing the E/M and the facture care on the same date of service. In this case you cannot unbundle the E/M with modifier 25, as 23500 is a procedure with a 90-day global period. In cases like this, you’ll typically use modifier 57 (Decision for surgery), depending on encounter specifics.

Other modifier example: Your physician excises a benign lesion from a patient’s upper left arm measuring 1.1 cm, and her left thigh measuring 0.9 cm.

On this claim, you should report 11402 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 1.1 to 2.0 cm) for the upper arm lesion and 11401 (… excised diameter 0.6 to 1.0 cm) for the thigh lesion.

Since the excisions occurred in the same body areas as far as the CPT® codes are concerned, you need to use a modifier on them to show medical necessity for the multiple services. Depending on payer preference, you could use modifier 59 or XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) if your payer is Medicare or a payer that recognizes Medicare modifiers. Other payers may also recognize another, non-NCCI-associated modifier: Modifier 51 (Multiple procedures).

Last, Stay Current on NCCI Changes

CMS makes quarterly changes to the NCCI PTP edit pairs that take effect every January 1, April 1, July 1, and October 1. “I make sure to review the changes each quarter by visiting CMS’ ‘Quarterly PTP and MUE Version Update Changes’ page at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes on or near each of these dates to prepare for what’s coming our way,” advises Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

The bottom line: Before using any modifier to separate same-day services, “it is important to understand the payer. What do they want to see? Do you need to send notes? And does the documentation clearly support the separate nature of the two services?” cautions Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.