Pediatric Coding Alert

You may no longer have the option of using modifier 59 to get around payers that include a screening with a preventive medicine service.

CPT 2008 puts an end to using modifier 59 (Distinct procedural service) on the screening code to indicate that the screening was a distinct procedure from the preventive medicine service. Keep your modifier 59 use on the up-and-up by adhering to these guidelines.

The AMA added "non-E/M" to modifier 59's description to further distinguish it from modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The description clarifies that you should use modifier 59 on procedure codes -- namely non-E/M services by stating "that a procedure or service was distinct or independent from other non-E/M services," says Catherine A. Brink, CMM, CPC, CMSCS, president of HealthCare Resource Management Inc. in Spring Lake, N.J.

Rule: You can use modifier 59 only to distinguish a procedure from a non-E/M service, not a procedure and an E/M. "Modifier 25 is used to report services or procedures separate from the E/M service, not 59," says Janet Smith, CPC, RHIT, coding educator for the Tennessee Chapter of the American Academy of Pediatrics in White House.

When reporting a screen, such as hearing (92551, Screening test, pure tone, air only), vision (99173, Screening test of visual acuity, quantitative, bilateral) or developmental (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report), with a preventive visit, "the appropriate modifier to use is modifier 25 on the preventive code" 99381-99385 (new patient preventive medicine service) or 99391-99395 (established patient preventive medicine service), Smith says.

You'll have to restrict your modifier 59 use to certain circumstances. CPT now specifies that your documentation must support a:

• different session

• different procedure or surgery

• different site or organ system

• separate incision/excision

• separate lesion or

• separate injury (or area of injury in extensive injuries).

With the revision, the modifier's applicability narrows from appropriate modifier 59 circumstances "may represent" to "documentation must support." Some experts previously suggested that Appendix A's inclusion of the above scenarios was merely as examples, not qualifying circumstances. "I have always felt modifier 59's use was limited to those examples," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders. "The 2008 CPT guidelines make the modifier's guidelines more crystal-clear."

Example: A pediatrician treats a patient for a first-degree burn on her elbow and a second-degree burn on her hand. Because the Correct Coding Initiative (CCI) indicates that 16000 (Initial treatment, first-degree burn, when no more than local treatment is required) is a component of 16020 (Dressings and/or debridement of partial-thickness burns, initial or subsequent; small [less than 5% total body surface area]), insurers may include 16000 in 16020 unless you append modifier 59 to 16000.

The modifier indicates that the physician treated the first-degree burn on a separate site from the dressing and/or debridement. Therefore, the pediatrician deserves payment for the normally bundled procedure.

Before using modifier 59, remember that it is the modifier of last resort. CPT warns that you should not use modifier 59 when another already established modifier is appropriate, unless no more descriptive modifier is available and as long as it best explains the circumstances, says Debra Pierce, MD, MBA, CPC, founder and managing member of Pierce MD Consulting LLC in Rockbridge, Ohio.

Right way: For payers that don't recognize units, use modifier 59 for additional different developmental screens. Smith says to report an established patient early childhood preventive medicine service with two developmental screens as follows:

• 99392-25 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... early childhood [age 1 through 4 years])

• 96110

• 96110-59.

Why: Modifier 51 (Multiple procedures) applies to claims involving surgical procedures, according to the AMA's Coding for Modifiers. Because no other modifier appropriately describes the interpretation and report of two different developmental screens, such as the PEDS and M-CHAT, the modifier of last resort -- 59 -- is appropriate to designate the second 96110 as a distinct and different procedural service from the initial 96110.

If an insurer allows you to use modifier 59 in place of 25 on claims involving a screening service, the revised language may make the payer align with CPT. The new "non-E/M" language may make insurers rethink and revamp their edits, Pierce says.

But payers can be slow to implement changes. "Alternately, insurers may operate with existing edits and practices," Pierce says.

Protect yourself: You must take proactive action if a plan continues to want modifier 59 as the vehicle for screening payment during a preventive medicine service. Obtain a reissued written acceptance of alternative billing arrangements for this scenario, Pierce says.