Pulmonology Coding Alert

Because these situations describe scenarios that may often arise in your practice, you might think that you will often append modifier -59 to separate services. However, many coders refer to -59 as the "modifier of last resort" and avoid using it unless they have to. Because of this difference of opinion, some practices aren't sure when they can and cannot report modifier -59.

"It's confusing because modifier -59 is the modifier of last resort, but it's also a National Correct Coding Initiative unbundler," says Jeff Fulkerson, BA, CPC, CMC, certified coder at Emory University in Atlanta. "If you're trying to separate services that NCCI normally bundles together, you should use a modifier to separate them, but it won't always be -59."

Use modifier -59 only when no other descriptive modifier fits the documentation, such as modifiers -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service; -58, Staged or related procedure or service by the same physician during the postoperative period; or -76, Repeat procedure by same physician. "If, after considering the other options, -59 is still the most appropriate modifier, you should report it," Fulkerson says.

Explanation: Generally, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky., you should use modifier -59 if the physician performed services at separate sessions or for different reasons on the same day.

Think of it this way: Modifier -59 tells the payer that the procedures were not components of one another but were actually both medically necessary and separate from one another, Corcoran says.

Want to increase your chances of coding success with modifier -59? Talk to your doctors, because your modifier -59 claims will go through a lot easier with good operative notes.

Pulmonology example: Mary Beth Wass, MC, CMM, manager at the Asthma and Allergy Center in Papillion, Neb., says that since code 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) was revised, her practice uses -59 more frequently than before.

You should report 94664, Wass says, when the medical staff evaluates and educates a patient on the correct use of a metered dose inhaler (MDI) or nebulizer. If the medical staff completes the education on the same day as a bronchospasm evaluation, as often is the case, you can append modifier -59, she notes. In this case, you should report 94060 (Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]), and you may also report 94664 with modifier -59 for the MDI evaluation and training, she says.

Bonus: Coverage by insurance carriers can vary, Wass says, so it is always best to check with them. "If the payer denies our request, we send a request for review to the carrier with copies of the pulmonary function report along with our MDI training check-off sheet," Wass says.

Watch out: Use caution when you append modifier -59. If you overuse this modifier, you may indicate "routine" unbundling of services to insurers, and they can initiate a review based on this suspicion. Your documentation must clearly identify the medical necessity and "separateness" of the "unbundled" service.

When your physician treats a patient with multiple conditions requiring multiple procedures, you may include modifier -51 on your claim to show that the physician performed the procedures at the same session.

Explanation: Some insurers, Corcoran says, might append modifier -51 on your code for you. Other insurers, such as Medicare, may prefer that you not add modifier -51 at all. This is one of the many instances when you must know your insurance company's guidelines before you use the modifier, Corcoran says. Some insurers may not recognize -51 at all and only pay you for one procedure (the most comprehensive) per date.

For example, all vaccine codes are exempt from modifier -51, and you should never append modifier -51 to these codes, even when the physician gives a vaccine (90476-90749) at the same session as another procedure.

Add-on codes are also exempt from modifier -51. For example, +31632 (...with transbronchial lung biopsy[s], each additional lobe [list separately in addition to code for primary procedure]), which you should report with 31628 (...with transbronchial lung biopsy[s], single lobe), is the code to report if the physician performs a biopsy on any additional lobes. Code 31632 is an add-on code, and you should never append modifier -51 to this code.

Hint: Add-on codes are marked in CPT with the (see symbol at right) symbol, and modifier -51 exempt codes are marked with the symbol.