Podiatry Coding & Billing Alert

Not adhering to the correct criteria could get you 'red flagged.'

A modifier in the right place at the right time is likely to get you a prompt and fair reimbursement. You use one of the most important modifiers - modifier 59 (Distinct procedural service) -- so often that you think you know everything there is to know about it. Review essential facts about modifier 59 and avoid hitting a blank wall before it's too late.

Guideline 1: Know Modifier 59's Criteria When You See It

The right combination of a podiatrist's procedure and a modifier can make or break your claim. If you want to be able to interpret a modifier correctly, read it like a story. Through modifiers, payers know what transpired during a procedure without having to go read every operative report, says Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC, coding and billing manager in Phoenix.

In the case of modifier 59, it indicates that a significant, separately identifiable procedure has been performed on the same day as another procedure, and often times during the same operative session. This modifier encompasses treatment for multiple primary, unrelated problems and may represent session or a different procedure site.

Example: A patient presents with a history of Morton's neuroma (355.6, Lesion of plantar nerve) on the left foot but also complains of right plantar heel pain. In this scenario, the podiatrist diagnoses neuroma on the left foot, and plantar fasciitis (728.71, Plantar fascial fibromatosis) on the right foot. If the podiatrist made an injection to treat the Morton's neuroma (64455, Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [e.g., Morton's neuroma]) and opted to treat the plantar fasciitis with a taping or strapping (29540, Strapping; ankle and/or foot), then you should append modifier 59 to 29540 to identify separate services.

If you think you could not be reimbursed for reporting both 64455 and 29540 on the same date of service, think again. You would have no problem with these two codes used at the same visit since they would have separate diagnosis done on different feet.

Guideline 2: Don't Overuse Modifier 59

You should use caution when using modifier 59 and be sure another modifier isn't more appropriate. In CMS memo A-00- 35, you'll discover that anatomical or bilateral modifiers may be more appropriate to use than 59. It says, "In those instances where an anatomic or the bilateral modifier is not more appropriate, modifier 59 may be appropriate. Report the most comprehensive code on the first claim line without a modifier.

On subsequent lines, report the ['bundled'] code with modifier 59 and the unit of service as equal to one."

Why: You have to prove within the operative report that significant separately identifiable procedures were done and that there is no better way to explain it to the payer. Ward adds that just like any modifier, the risks in using or overusing modifier 59 come into play when you use it incorrectly. "As a coder it is our responsibility to verify when procedures performed are bundled together with respect to the CCI edits. In not doing so, and by just appending modifier 59 to codes that we feel need it, we open ourselves and our practices to being 'red flagged' for a possible audit," she continues.

Modifier 59 is dubbed as a "modifier of a last resort" because its descriptor says that you should only use it "if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances."

Guideline 3: Draw the Line between Modifiers 59, 51

Don't confuse modifier 59 with modifier 51 (Multiple procedures), which is used to identify secondary "allowable" procedures or services provided along with the primary procedure.

Some coders consider modifier 51 as an indicator to payers that multiple procedures were done during one operative session, while modifier 59 as more of a "bundling/unbundling" modifier, which is typically used to indicate that procedures normally considered 'components' of one another (therefore not separately reimbursable) are in certain cases to be looked at 'individually.'

To ensure reimbursement using this modifier, you would have to indicate which of the multiple procedures is 'primary' since many payers allow for 100 percent of allowable for only theprimary procedure and drop payment for subsequent procedures to 50, or even 25 percent.

Example: If you are billing for a repair of a rotator cuff (23412, Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic), a ligament release (23415, Coracoacromial ligament release, with or without acromioplasty), and a claviculectomy (23120, Claviculectomy; partial), report the codes as follows:

• 23412
• 23415 - 51
• 23120 - 51

Guideline 4: Equip Yourself with Reminders

Overall, you have 7 key points to remember when using modifier 59. They are:

• Documentation is vital to support medical necessity.
• Be sure that your patient's medical record is well documented.
• This modifier may represent a different body site or organ system.
• This modifier may represent a separate lesion.
• This modifier may represent a different area of injury.
• This modifier may represent a different procedure.
• This modifier may represent a separate incision or excision.
• This modifier represents a distinct and independent procedure/surgery/encounter from other services performed on the same day.

Remember that modifier 59 is a handy story teller for coding and billing podiatry procedures. However, be ready to drop it when you don't need it, and you might dodge a potential audit.