Pulmonology Coding Alert

Question: Recently, I have received denials for services to which I appended modifier 59. Can you explain what I may be missing about reporting distinct procedural services?

Texas Subscriber

Answer: You're not alone -- modifier 59 (Distinct procedural service) is often used incorrectly. In the eyes of the Correct Coding Initiative (CCI), modifier 59's primary purpose is to indicate that the physician performed two or more procedures:

• at different anatomic sites, or

• during different patient encounters.

Helpful: From an CCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. The definition, however, does not include treatment of contiguous structures of the same organ.

Only use modifier 59 if no other modifier more appropriately describes the relationships of the two or more procedure codes you are reporting. Look to the CCI edits to determine when you may not report two CPT or HCPCS codes together, except under special circumstances.

You should not use modifier 59 or other CCIassociated modifiers to bypass an CCI edit unless the proper criteria for using the modifier is met. Documentation in the medical record must satisfy the criteria required by any CCI-associated modifier that you use.

One of the misuses of modifier 59 is related to its permissible use to describe "different procedure or surgery."The descriptors of the two codes of a code pair edit, however, usually represent different procedures or surgeries, so the provider cannot use modifier 59 for such an edit to unbundle components of a standard surgical procedure that a physician commonly performs together. But if the physician performs the two procedures/surgeries at separate anatomic sites or at separate patient encounters on the same date of service, you may append modifier 59 to indicate that they are different procedures/surgeries on that date of service.

Example: If a pulmonologist performs a bronchoscopy to obtain bronchial biopsies as well as transbronchial lung biopsies, report 31628 first and 31625 (Bronchoscopy with biopsy)-59 attached. Keep in mind that the pulmonologist must garner the transbronchial lung biopsies from a different area than the bronchial biopsies.

Be aware that there is an CCI edit on 31625 when it is used with either a transbronchial lung biopsy (31628) or a transbronchial needle aspiration (31629).

CCI, however, does not require different diagnoses for each procedure to use modifier 59. On the other hand, different diagnoses are not adequate criteria for using modifier 59.