Pediatric Coding Alert

Understand the wrong, and the right, ways to use modifier 59.

Like many coders, you’ve probably come to think of modifier 59 (Distinct procedural service) as the “unbundling modifier.” That’s because it is one of the first modifiers you think to use when you have to unbundle National Correct Coding Institute (NCCI) procedure-to-procedure (PTP) edit pairs.

Indeed, “the 59 modifier can be very useful when the time is appropriate,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. However, its overuse, and particularly its misuse, means “that payers are taking long looks whenever it is used,” Hauptman cautions.

That’s why we’ve busted three unbundling modifier myths to help you avoid that scrutiny and any payment denials that can come with it.

Myth 1: You Can Use Modifier 59 to Unbundle Any NCCI Edit

This myth seems to have its origins in Centers for Medicare and Medicaid (CMS) guidelines, which tell you to apply the modifier:

• for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers” (Source:  www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf).

On the surface, this sounds like CMS allows you to use modifier 59 to override an edit pair whenever the service described in the second code (the column 2 code) is regarded as being a part of, or overlapping with, the service described in the main, or column 1, code.

However, like any modifier, you cannot use modifier 59 to unbundle NCCI edit pairs with a modifier indicator of 0. That’s because CMS guidelines state that, for any edit pair with a 0 indicator, “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider” (Source:  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

That means you can only use modifier 59, or any other modifier, to unbundle two procedures when the modifier indicator is 1. For example, 94640 (Pressurized or nonpressurized inhalation treatment …) is a column 1 code with 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator …). The edit pair carries a modifier indicator of 1, so appending modifier 59 to 94664 will unbundle the services. This will allow you to get reimbursed for both procedures, providing your documentation can substantiate that your pediatrician performed the procedures separately on the same date or on separate occasions.

Myth 2: Only Modifier 59 Will Unbundle Procedures

As useful as it is, modifier 59 is not the only modifier you can use to unbundle procedures.

Modifiers for specific anatomic sites, for example, may be more appropriate under the right circumstances. So, look into using RT (Right side), LT (Left side) and modifiers for the left thumb (FA), left fingers (F1-F4), right thumb (F5), right fingers (F6-F9), left big toe (TA), left toes (T1-T4), right big toe (T5), and right toes (T6-T9) as determined by your pediatrician’s notes.

Additionally, while private payers have been slow to adopt them, you may have the option to use an X modifier from the following:

• XE (Separate encounter …), which you can use for multiple encounters on the same date;
• XS (Separate structure …), which you can use when the same procedure is performed on different structures;
• XP (Separate practitioner …), which you can use when different practitioners perform the same procedure; and
• XU (Unusual Non-Overlapping Service …), which you can use when your pediatrician performs different services on the same structure or anatomical site that involve distinct components.

These modifiers “better define why you feel the need to modify the service you are submitting,” Hauptman notes. But in order to use these codes, “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?” Hauptman cautions.

Myth 3: Modifier 59 Can Unbundle E/M Services, Too

Finally, “you would never use modifier 59 on an E/M [evaluation and management] service,” cautions Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin. Scenarios like this require the use of modifiers 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) or 57 (Decision for surgery), depending on encounter specifics.

In general, modifier 25 should be used on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period, while procedures with a 90-day global period will typically take modifier 57.