Practice Management Alert

Myth: Always use 59 to unbundle same-session, different-reason procedures

If you always apply modifier 59 and unbundle two procedures that the Correct Coding Initiative (CCI) bundles when a physician performs them during the same session but for different reasons, you had better rethink your modifier usage. You can apply modifier 59 (Distinct procedural service) only if the two procedures were in different sessions, were in different anatomical areas or were otherwise totally unrelated.

The bottom line: Missing the mark on modifier 59 is sure to get you in trouble with auditors.

Prepare for Greater Scrutiny

Many providers and billers believe that they can use modifier 59 as long as they have different diagnoses or reasons for the procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City. This is a no-no, and the HHS Office of Inspector General has warned about this sort of overuse.

Why: Medicare could save $538 million by reducing improper use of modifier 25, and $59 million by cutting back on the inappropriate use of modifier 59, the HHS Office of Inspector General insists in its 2007 compendium of unimplemented recommendations.

What it means to you: Expect your carriers to be scrutinizing your modifier 25 and 59 claims.

Example: A patient comes in for a colectomy for colon cancer, but the patient also has a ventral incarcerated hernia that requires a complex repair using mesh. The CCI considers hernia repair code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated) to be part of partial colectomy code 44140 (Colectomy, partial; with anastomosis) because the hernia repair is integral to the closure, Cobuzzi says.

Wrong: You might think you can append modifier 59 to the hernia repair code and bill it separately. After all, the hernia repair may be for a totally different reason than the colectomy, such as the patient's recurrent hernia. But modifier 59 tells the carrier the hernia repair happened at a separate session, which isn't true.

Correct answer: Instead, if justified by the physician's documentation, you could try appending modifier 22 (Unusual procedural services) to the colectomy code because of the extra time and effort the complex hernia repair requires. Make sure the documentation supports the additional substantial complexity of the hernia repair and mesh implantation, Cobuzzi says. You may have to fight for the additional money, she adds.

Look at Other Modifiers First

The modifier 59 guidelines say that if another modifier is appropriate, such as if it defines the site of the procedure better, you should use it instead of modifier 59, Cobuzzi says. For example, you should use modifiers LT (Left side) and RT (Right side) to indicate anatomical location.

For example: The physician performed a partial ethmoidectomy (31254) on the left side and a total ethmoidectomy (31255) on the right side. So you would bill those with modifiers LT and RT respectively.

Unfortunately, many payers, including some Medicare carriers, have a hard time recognizing these modifiers. So you may end up having to use modifier 59 after all with those carriers. Similarly, Medicare is supposed to pay for multiple units of lesion removal codes, but with some carriers you may have to bill the same code multiple times using modifier 59 instead.

Bottom line: You will use modifier 59 for two separate sessions during which the physician provides services that are normally bundled when done in a single patient encounter, Cobuzzi says.

For example: A patient comes in complaining of nasal congestion, postnasal drip, headaches and dry mouth. The doctor does a diagnostic nasal endoscopy (31231) at 10 a.m. Then, that evening the same patient comes into the emergency department with a huge nosebleed. The ED physician can't stop the bleeding and calls in the patient's ear, nose and throat specialist. The ENT physician can bill for controlling the interior nosebleed (30903).

Normally, CCI bundles 31231 into 30903, but in this case the ENT physician is justified in using modifier 59. The column-two code is 30903, so you should append modifier 59 to that code.