Pulmonology Coding Alert

Make sure you adhere to the correct criteria or suffer being 'red flagged.'

A modifier in the right place at the right time is likely to get you a prompt and fair reimbursement. You use one of the most important modifiers -- modifier 59 (Distinct procedural service) -- so often that you think you know everything there is to know about it. Review essential facts about modifier 59 and avoid hitting a blank wall before it's too late.

Guideline 1: Know Modifier 59's Criteria When You See It

The right combination of a pulmonologist's procedure and a modifier can make or break your claim. "Every modifier tells a story," says Susan Ward, CPC, CPC-H, CPC-I, CPCD,CEMC, CPRC, coding and billing manager in Phoenix. Through modifiers, payers know what transpired during a procedure without having to go read every operative report.

Modifier 59 indicates that a significant, separately identifiable procedure has been performed on the same day as another procedure, and often times during the same operative session. This modifier encompasses treatment for multiple primary, unrelated problems and may represent session or a different procedure site.

Example: A patient with a left upper lobe infiltrate undergoes a transbronchial lung biopsy (31629). During the bronchoscopy,the pulmonologist finds a right mainstem lesion, which she biopsied (31625). You should add modifier 59 to the bronchial biopsy code (31625-59) indicating that the endobronchial biopsy was performed at a site different from the transbronchial biopsy. Why? There is a Correct Coding Initiative edit involving 31625 and 31629 which you can unbundle with modifier 59. You should use 793.1 (Abnormal chest radiograph) to report the pulmonary infiltrate.

Guideline 2: Don't Overuse Modifier 59

You should use caution when using modifier 59 and be sure another modifier isn't more appropriate. In CMS memo A-00- 35, you'll discover that anatomical or bilateral modifiers may be more appropriate to use than 59. It says, "In those instances where an anatomic or the bilateral modifier is not more appropriate, modifier 59 may be appropriate. Report the most comprehensive code on the first claim line without a modifier.On subsequent lines, report the ['bundled'] code with modifier 59 and the unit of service as equal to one."

Why: You have to prove within the operative report that significant separately identifiable procedures were done and there is no better way to explain it to the payer, reminds Ward.

She adds that just like any modifier, the risks in using or overusing modifier 59 come into play when you use it incorrectly. "As a coder it is our responsibility to verify when procedures performed are bundled together with respect to the CCI edits. In not doing so, and by just appendingmodifier 59 to codes that we feel need it, we open ourselves and our practices to being 'red flagged' for a possible audit," she continues.

Usually dubbed as a "modifier of a last resort," modifier 59's descriptor says that you should only use it "if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances."

Guideline 3: Draw the Line Between Modifiers 59, 51

Don't confuse modifier 59 with modifier 51 (Multiple procedures),which is used to identify secondary "allowable" procedures or services provided along with the primary procedure.

"I see modifier 51 as an indicator to payers that multiple procedures were done during one operative session," says Sylvia Thompson, CPC, billing supervisor, Rady Children's Hospital in San Diego. She gets to facilitate issuance of reimbursement by indicating which of the multiple procedures is 'primary.' "Many payers allow for 100 percent of allowable for only the primary procedure and drop payment for subsequent procedures to 50, or even 25 percent," she adds.

Hint: It is not necessary to use modifier 51 when your pulmonologist performs multiple bronchoscopy procedures on the patient during one bronchoscopy session. The payment is made based on the multiple endoscopy rule, which allows full reimbursement for the most complex bronchoscopy code and the sum of the differences between each of the less complex bronchoscopy codes and the base bronchoscopy code, 31622.

Meanwhile, Thompson thinks that modifier 59 is more of a "bundling/unbundling" modifier, which is typically used to indicate that procedures normally considered 'components' of one another (therefore not separately reimbursable) are in certain cases to be looked at 'individually.'

Important: Always attach modifier 59 to the code -- regardless of value -- that would otherwise be denied or is a component of another, more comprehensive code.

Guideline 4: Equip Yourself with Reminders

Overall, there are 7 key points to remember when you're using modifier 59. They are:

Documentation is vital to support medical necessity.

Be sure that your patient's medical record is well-documented.

This modifier may represent a different body site or organ system.

This modifier may represent a separate lesion.

This modifier may represent a different area of injury.

This modifier may represent a different procedure.

This modifier may represent a separate incision or excision.

This modifier represents a distinct and independent procedure/surgery/encounter from other services performed on the same day.

Remember that modifier 59 is a handy story teller for coding and billing pulmonary procedures. However, be ready to drop it when you don't need it, and you might dodge a potential audit.