Practice Management Alert

Question: I've heard it's easy to get bundled services paid separately by simply using modifier 59. Is that true?

Answer: The short answer is "yes." Appending 59 (distinct procedure) to a code will essentially override an NCCI edit indicating it should be bundled with something else. But while using this modifier will usually get you paid, it doesn't mean you should be paid, and the feds often come after what they see as inappropriate reimbursement with a vengeance.

"It is a very dangerous modifier because a lot of times people think of it as a license to unbundle," says Barbara Cobuzzi, MBA, CPC, ChBME, president of Cash Flow Solutions in Lakewood, NJ. "If you disagree with a bundle that is part of NCCI, using 59 because you're mad about the bundle isn't appropriate," warns Cobuzzi. "Yes, you can get paid, but can you keep it and defend it  and defend that you weren't committing fraud?" she asks.

     To test whether you're using 59 appropriately, ask yourself the following questions:

1. Is it a separate site?

2. Is it a separate session?

3. Could I defend my use of 59 in a court of law?

4. Does the physician documentation support the use of 59?

5. Does the NCCI allow me to use the 59 modifier? If the answer to each of these questions is "yes," you're in good shape. If not, think long and hard before putting that 59 on your claim.

A lot of the confusion about 59 might come from the modifier indicators in NCCI, suggests consultant Cindy Parman, CPC, CPC-H with Coding Strategies, Inc. in Atlanta. If the modifier indicator is '0,'that means the "modifier will not bypass [the] bundling edit," and a '1' means the "modifier is allowed and will bypass [the] edit," she notes.

Lesson: That doesn't mean, however, that if the indicator is '1,' you should necessarily use the modifier, Parman clarifies. "When a code combination lists indicator '1,' it means that if the documentation supports a separately identifiable service then it is appropriate to apply the modifier 59." But if the physician performed both services in the same session or if one service "was integral to the other," you absolutely should not use 59.

Think of 59 as the "Modifier of Last Resort," Parman instructs. Before using it, run through the other modifiers to see if a different one is more appropriate. "Examples would be 76/77 (repeat services on the same date), 58 (staged procedure) or 78/79 (return to the operating room)," she offers.