Pediatric Coding Alert

Question: One of our private payers denied two types of allergy testing that we reported on the same day. Both procedures were performed on the same day so the payer says 95024 is incidental to 95027. Do we need to append modifier 58 to show it’s a staged procedure? 

Answer: CCI (Correct Coding Initiative) edits bundle 95024 (Intracutaneous [intradermal] tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests) with 95027 (Intracutaneous [intradermal] tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of tests) but it can be overridden by using modifier 59. For some reason, the payer might be trying to create its own bundles. 

Appeal the denial, but check about modifier usage before resending the claim. Modifier 59 (Distinct procedural service) should be used rather than modifier 58 (Staged or related procedure or service by the same provider or other qualified health care professional during the postoperative period).

CMS guidelines teach that modifier 58 should be used when your provider performs a second surgery during the postoperative period of another surgery when the subsequent procedure was: 

• planned or "staged" or 
• more extensive than the original procedure; or 
• for therapy following a surgical procedure; or 
• for the reapplication of the cast within the 90-day global period.

Modifier 59, by contrast, shows that your provider completed both services for separate reasons (and you should have the documentation to support it). It’s a more appropriate modifier for the allergy tests you describe since everything took place on the same day and during the same encounter.