Podiatry Coding & Billing Alert

When your podiatrist performs two medically necessary procedures during the same session, knowing the ins and outs of modifier 59 is essential for your coding.

The problem: Modifier 59 (Distinct procedural service) is one of the most misunderstood modifiers. Avoid problems  -- and get your claims paid -- by following these proven tips:

The Office of Inspector General (OIG) and many payers, including Medicare, continually review physicians' modifier 59 use. In fact, according to a 2005 review by the OIG and an independent contractor, 40 percent of code pairs studied did not meet program requirements for proper modifier 59 use. In addition, the study found that physicians did not adequately document in 25 percent of the billed code pair cases.

There are circumstances when you can  -- and should -- use modifier 59, however. For instance, you may use modifier 59 to identify procedures that are distinctly separate from another procedure provided by your podiatrist on the same day. In addition, you may append 59 to your claim when your physician:

• sees a patient during a different session,

• treats a different site or organ system,

• makes a separate incision/excision,

• tends to a different lesion, or

• treats a separate injury.

Example: Your podiatrist performs a strapping procedure on the big digit of the patient's right foot (29550, Strapping; toes). The podiatrist also injects a therapeutic agent into the left foot (20550, Injections[s]; single tendon sheath, or ligament, aponeurosis [e.g.,plantar "fascia"]). The Correct Coding Initiative (CCI) bundles 20550 (the column 1 code) into 29550 (the column 2 code). Since your podiatrist performed the procedures in different anatomic locations, you can bypass the bundling edit by appending modifier 59 to 29550.

Important: You can never use modifier 59 for E/M services, says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas. If you're reporting  a separately identifiable E/M service with another  procedure on the same day, you'll turn to modifier 25  (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

If you are unsure whether two procedures are subject to bundling edits, check the CCI edits. The CCI edits list two codes as "mutually exclusive" of one another or pair them together ("bundles" them). If you see reference to "column 1" and "column 2" codes, CCI bundles the procedures and normally you would not report them together.

Unbundling is not automatic: Be aware, Kernaghan says, that you can't automatically override a CCI edit with modifier 59 just because documentation supports a separate site, incision, or patient encounter.

Here's why: Before appending modifier 59, check the modifier indicator for the bundled code pair. You'll find the modifier indicator in Column F of the CCI Excel spreadsheet, which you can download from  www.cms.hhs.gov/NationalCorrectCodInitEd.

A modifier indicator of "0" means that you may not unbundle the edit combination under any circumstances. Alternately, a "1" indicator opens the possibility foryou to override an edit using a modifier if you can verify that the procedures are distinct from one another.

Example: Your podiatrist administers steroid injections into a plantar common digital nerve on the right foot to relieve pain arising from Morton's neuroma on the right foot. He also injects a neurolytic agent into the neuroma on the left foot to relieve chronic pain. Both procedures were performed during the same session. Because the podiatrist administered the injections on different nerves, you can separately report the procedures. Report the steroid injection with 64455 (Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [eg, Morton's neuroma) and the neurolytic agent injection with 64632 (Destruction by neurolytic agent; plantar common digital nerve). Append modifier 59 to 64455. This tells the payer you're legitimately overriding the CCI edit because your podiatrist performed a separate procedure, and you should be paid for both. You should also add modifier LT (Left side) or RT (Right side) to indicate which foot was involved.

How it works: Attach modifier 59 to the procedure code in column 2 (64455 in this example). If you break a CCI edit or bill for a separate procedure as outlined by the CPT, append 59 to the "separate procedure" code found in column 2.

Pitfall: For mutually exclusive code pairs, don't assume that the higher-paying code is the one to which you should attach modifier 59. Check the CCI edits to see which code is listed in column 2.

When you're trying to decide whether you should append modifier 59, use a logical approach. Ask: Did the second procedure require a separate approach or site?

Although modifier 59 is on the OIG watch list, there is less risk of overusing it if it's well supported, says Rena Hall, CPC, a billing/insurance specialist in Kansas City, Mo.

Important: Never use modifier 59 just to get paid for a procedure. "Make sure there is well-documented support for a separate and distinct procedure before adding modifier 59," Hall points out. In addition, CPT instructions dictate that if a more specific modifier describes the situation, you should not use modifier 59. "Modifier 59 should be used as a modifier of last resort," Kernaghan confirms.