Pulmonology Coding Alert

Changes aren’t earth-shattering, but do help provide clarity on this frequently-used modifier.

Chances are that your pulmonology practice has used modifier 59 more than a few times in the past, but odds are also high that some of your staff members are confused about when it applies and when it doesn’t. CMS has tried to make that determination a little simpler with a transmittal update. Pulmonology Coding and Billing Alert checked out the changes and picked out the most important facts – read on to find out the scoop.

Background: On December 28, CMS issued an update to Transmittal 4188, with an implementation date of January 30, 2019. As part of its clarification to the National Correct Coding Initiative (NCCI) section of the Medicare Claims Processing Manual, the transmittal spells out the requirements for when modifier 59 (Distinct procedural service) is appropriate. CMS has published such information elsewhere, but the agency has now taken the step of adding this verbiage to chapter 23 of the Manual.

A summary of the changes – along with pulmonology-specific examples – are below.

Check These Examples of When You Can – And Can’t -- Use Modifier 59

Example 1: “Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ,” the transmittal states.

Pulmonology-Specific Scenario: The pulmonologist performs a bronchoscopy with left lobe endobronchial biopsy, as well as a left lower lobe transbronchial biopsy. You can report both the endobronchial biopsy and the transbronchial biopsy together since they are in different sections of the lung, but modifier 59 will be essential for payment, as follows:

• 31628 -- Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe 
• 31625-59 -- Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites 

Example 2: “Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different,” the transmittal says.

Pulmonology-Specific Scenario: A patient presents for a diagnostic bronchoscopy, but during the procedure, the physician also performs a biopsy unexpectedly. The physician reports the following codes:

• 31622-59 -- Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)
• 31625 -- Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites

In this case, you cannot append modifier 59 to 31622 – in fact, you can’t report 31622 at all, even though the descriptors are different on the two codes. The reality is that if you perform a more extensive procedure, you should report only the most comprehensive code. Here, 31625 is the more extensive procedure, so in this situation, that’s the only code you should bill.

Example 3: “Modifier 59 is used appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure,” the transmittal notes.

Pulmonology-Specific Scenario: A patient performs a six-minute walk and the pulmonologist determines that her responses suggest a more involved lung condition. She then decides to order a bronchodilation responsiveness study to see if the patient’s respiratory status improves after bronchodilation. Because a PFT involving spirometry measures lung volume (vital capacity and/or forced vital capacity) and flow, while the six-minute walk test evaluates the patient’s exercise capabilities, you can report both codes as follows:

• 94618 -- Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed
• 94060-59 -- Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration 

Keep in mind: In all of the above examples, the transmittal states, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59.”

Therefore, you need not document different diagnosis codes to justify the use of modifier 59 – and you shouldn’t assume you can separate NCCI edits just because you have separate ICD-10 codes.

Resource: To read CMS Transmittal 4188, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf.

Modifier 59 Isn’t Automatically the Best Choice

Although CMS has clarified its regulations for when you can report modifier 59 (Distinct procedural service), that doesn’t mean you always should append it when reporting codes together that are typically bundled under the Correct Coding Initiative.

In some cases, other modifiers may be more appropriate, and in those situations, you should report these modifiers instead of 59. Be sure to check if non-Medicare payers accept alternative modifiers. Alternative modifiers may include the following, among others, depending on the circumstances:

• Modifier XE -- Separate encounter
• Modifier XS  -- Separate structure
• Modifier XP -- Separate practitioner
• Modifier XU -- Unusual Non-Overlapping Service
• Modifier 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
• Modifier LT-- Left side
• Modifier RT-- Right side
• Modifier 57 -- Decision for surgery