Pulmonology Coding Alert

Heightened OIG scrutiny may make or break distinct procedure reimbursements

Modifier -59 may seem like an easy way to collect when you bill bundled procedures together because you may gain extra reimbursement for your two procedure claims, but think twice before appending -59 (Distinct procedural service). You could be asking for a world of denial woes.

Watch out: In its recently released 2005 Work Plan, the Office of Inspector General (OIG) at the Department of Health and Human Services stated that it intends to scrutinize claims that include modifiers used to bypass NCCI edits. Therefore, it's more important than ever before to ensure that you're using modifier -59 appropriately.

Although several modifiers allow practices to unbundle National Correct Coding Initiative (NCCI) edits, pulmonology practices most often choose modifier -59 in order to separate code pairs.

To avoid running afoul of CMS regulators, always be sure the physician's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59.

Follow our experts' advice to determine when you should - and should not - append modifier -59 to your claims.

Modifier -59 Works When Codes Are Close

Pulmonology coders use modifier -59 to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.

Think of it this way: Modifier -59 tells the payer that the procedures were not components of one another but were both medically necessary and separate from one another, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Beware: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary. If you overuse this modifier, you may indicate routine unbundling of services to insurers, and they can initiate a review based on this suspicion, coding experts say. Your documentation must clearly identify the medical necessity and separateness of the unbundled service.

If Other Modifiers Will Do the Job, Avoid -59

You should never use modifier -59 if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant.

In other words, -59 "is the modifier of last resort," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.

Note: See our modifier -59 decision tool on page 3 to help you determine when you should select modifier -59 rather than other modifiers.

Coding example: The pulmonologist completes a second bronchoscopy (31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]) on the same date of service as the one she performed earlier on a patient whose condition has changed.

In this case, you should report 31622 with modifier -76 (Repeat procedure by same physician) because the physician repeated the same procedure.

Asthma Visits Offer -59 Opportunities

A common modifier -59 scenario in pulmonology practices involves patients who receive nebulizer treatments and instructions on the same day.

Example: A 5-year-old established patient newly diagnosed with asthma reports with still-worsening symptoms and needs to be checked for medication adjustments. The pulmonologist performs a level-three E/M service, administers a nebulizer treatment and then decides that home treatments are necessary for the patient.

He instructs the patient and his parents about how to conduct home nebulizer treatments before sending the child home. The claim should read: