Radiology Coding Alert

Question: In your August article "Modifiers -51 and -59: Under the Microscope," you recommended that coders should report modifier -59 when attempting to unbundle National Correct Coding Initiative (NCCI) edits. One of our private payers uses the NCCI edits but does not recognize modifier -59, and this causes a lot of denials. What should we report instead?

Massachusetts Subscriber

Answer: Many private payers do not honor certain modifiers, and modifier -59 (Distinct procedural service) tops the list.

Because your insurer recognizes the NCCI edits, you should ask the payer how you should submit claims that would normally warrant modifier -59. You may need to ask such payers to include language in their participation contracts that advises how to process such claims. This way, you can protect your reimbursement rights and ensure reimbursement when you perform two medically necessary services that other payers allow you to report using modifier -59. The insurer may ask you to submit the claims on separate claim forms or append a different modifier instead.