Primary Care Coding Alert

Know how to use, but not misuse, the “unbundling modifier.”

When it comes time to unbundle National Correct Coding Institute (NCCI, or CCI) procedure-to-procedure (PTP) edit pairs such as the ones highlighted in the first article of this issue, one of the first modifiers you might think to use is 59 (Distinct procedural service). In fact, modifier 59 gets so much use in this context that it has become known as the “unbundling modifier.”

But before you reach for modifier 59 to unbundle any of the CCI PTP edit pairs, make sure you go through this list of dos and don’ts to make sure you are using it correctly. In some cases, another modifier may actually be your best bet.

DO Understand CMS Guidelines for 59 Use

“The 59 modifier can be very useful when the time is appropriate,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “But it’s being so misused that payers are taking long looks whenever it is used,” Hauptman cautions.

Consequently, it is important for you to understand and apply the guidelines for its use. In its article on modifier 59, the Centers for Medicare and Medicaid (CMS) spells out exactly when the modifier should be applied:

“One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers” (Source: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf).

This means that whenever CCI has determined you should not report two procedures together because the service described in the second code (the column 2 code) is regarded as being a part of, or overlapping with, the service described in the main, or column 1, code, the edit can be overridden by using the appropriate modifier depending on the modifier indicator assigned to the pair under certain circumstances.

DON’T Use Modifier 59 When Indicator is 0

You’ll only be able to use modifier 59, or any other modifier for that matter, to unbundle two procedures when the modifier indicator is 1. If it is 0, “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider,” according to CMS. (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

DO Use 59 to Indicate Separate Sessions, Services, Surgeries, Sites, or Systems

The CMS modifier 59 article goes on to state that you should use the modifier if your documentation supports “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) not ordinarily encountered or performed on the same day by the same individual.”

Example 1: “If a primary care provider injected a shoulder due to bursitis and also injected a knee for osteoarthritis, you would probably use 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) for both services,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin. “Generally, the appropriately linked diagnosis code should get both services paid so that they are not identified as duplicate charges. However, some payers will want modifier 59 reported to indicate separate locations,” Rasmussen notes.

Example 2: “If you report 11719 [Trimming of nondystrophic nails, any number] as a column 1 code with 11720 [Debridement of nail(s) by any method(s); 1 to 5] as a column 2 code, you will need to append modifier 59 to the column 2 code to be reimbursed for both procedures, providing your documentation can substantiate that the provider performed the procedures on separate nails or on separate occasions,” Rasmussen further elaborates.

In this case, 11719 and 11720 are an edit pair that carries a modifier indicator of 1 when 11719 is the column 1 code, so appending modifier 59 to 11720 will unbundle the services.

DON’T Use 59 When Other Modifiers Add More Specificity

Confusingly, modifier 59 is not the only modifier you can use to unbundle procedures. If the situation allows, you may be able to use modifiers for specific anatomic sites, including RT (Right side), LT (Left side) and modifiers for specific fingers (F1-F9 and FA) and toes (T1-T9 and TA).

Additionally, since 2015, you have also had the option to use one of the X modifiers that CMS introduced to eventually replace 59:

• XE — Separate encounter
• XS — Separate structure
• XP — Separate practitioner
• XU — Unusual Non-Overlapping Service.

More and more payers are recognizing these modifiers, so be sure to check with them before using one when the situation allows.

Coding caution: “The X modifiers better define why you feel the need to modify the service you are submitting,” Hauptman notes. “But it is important to understand the payer. What do they want to see? Do you need to send notes? And does the documentation clearly support the separate nature of the two services?” Hauptman adds.

DON’T Use 59 on E/M Services

Finally, “you would never use modifier 59 on an E/M [evaluation and management] service,” Rasmussen cautions. Scenarios like this require the use of modifiers 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or 57 (Decision for surgery), depending on encounter specifics.