Radiology Coding Alert

Use mod -59 for procedures you don't normally report together

When your radiologist takes x-rays on the same patient in different sessions on the same day, do you always report only one code? If the radiologist provides multiple ultrasounds in the same session, do you assume that only one procedure is reportable?

If you answered "yes" to either of these questions, you may not be taking advantage of all situations when you can use modifiers -59 and -51. Read on for more information on these modifiers to help you when reporting related codes on the same claim.

Use Mod -59 When Codes Are Close

Radiology coders use modifier -59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.

In general, radiology coders append modifier -59 to procedure codes when the radiologist:

sees a patient during a different session;

treats a different site or organ system;

sees a patient during a different encounter;

treats a different organ system, or

treats a separate injury.

Modifier -59 is "used when multiple procedures in the same (code areas) are performed at the same time," says Linda Parks, MA, CPC, CMC, CCP, coding specialist in Marietta, Ga.

Example: Let's say a patient is referred to the radiologist for an x-ray of the abdomen at 10:15 a.m. The radiologist takes a single view and the patient leaves. At 4:33 p.m. the same day, the patient returns with a worsened abdominal condition. This time, the radiologist takes a complete abdomen x-ray with erect and chest views. The claim for this example should read:

CPT 74022 (Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest)

CPT 74000 ( ... single anteroposterior view) with modifier -59 to show there were two distinctly different x-ray sessions.

Pay Attention To Coding Initiative Edits

Parks reminds coders to stay on top of the National Correct Coding Initiative (NCCI) edits, so you're always aware of which codes are modifier -59 exempt.

Not sure on NCCI? If you're stuck on whether you should bill codes with the -59 modifier, check the NCCI edits. If the codes you are reporting have indicators of "1" next to them, this means you can append the modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.

Time Saver: Increase your mod -59 reimbursement rate by appending it only when absolutely necessary, experts recommend.

Many private payers do not require the use of a modifier for multiple-procedure scenarios, or don't recognize -59 as a legitimate modifier. Check with your individual payer to see if the -59 modifier is necessary when reporting multiple-procedure claims, says Parks.

And when you do have to report a modifier to solidify a claim, there are often much better options than modifier -59. In radiology offices, there are times when claims that end up tagged with the -59 mod should have had a different modifier attached, such as:

modifier -78 (Return to the operating room for a related procedure during the postoperative period) or

modifier -79 (Unrelated procedure or service by the same physician during the postoperative period).

Tip: Each time you are unsure whether a carrier accepts modifier -59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification.

Then, chart each carrier's policies on -59 so you know whether to use it the next time you file a claim. These phone calls may take a little time, but once you get a chart with each insurance company's policy on modifier -59, your claims department will be streamlined.

Having heeded all of the previous warnings, remember: Don't be afraid to use the -59 modifier if you have to -- just make sure you've exhausted all other options and you are using it as it was intended, as the "modifier of last resort."

Use Mod -51 For Multiple Procedures

When your radiologist treats a patient that requires multiple procedures, you would include modifier -51 (Multiple procedures) on your claim.

Mod -51 is "an informational-type modifier ... for use on the second, third, etc. surgical procedure [the radiologist] performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

Example: Apatient with unusually heavy menstrual bleeding is referred to the office for an ultrasound. The radiologist performs a standard transabdominal pelvic ultrasound, during which the technician finds a suspicious uterine mass. The radiologist cannot get a clear view of the mass due to its location, so he takes a transvaginal approach to gain better sight of the abnormality.

The claim for this example should read:

76856 (Ultrasound, pelvic [nonobsteric], B-scan and/or real time with image documentation; complete)

76830 (Ultrasound, trasnvaginal) with mod -51 appended to describe the transvaginal ultrasound as a separate service AND ICD-9 code 626.2 (Excessive or frequent menstruation)

Why? The -51 modifier is appropriate because you need to show the insurance company that you had to perform two ultrasounds, and you aren't "double-dipping" on the claim.

Mod -51 shows the insurance company that although the multiple procedures were related to each other due to anatomic area, separate ultrasounds were necessary, says Riesser.

Check RVUs Before Ordering Codes

On modifier -51 claims, the code that stands alone is the code that insurers will pay in full, so make sure you attach modifier -51 to the code with the lower RVU. "Modifier -51 prevents the insurance company from changing the order of your codes, because the most expensive procedure should be listed first," Riesser says.

In the above example, both 76856 and 76830 have non-facility RVUs of 2.58, so code order wouldn't matter in this case. But you should check RVUs for each procedure when reporting, just to make sure that you aren't depriving your office of reimbursement it is entitled to.

Remember: Although reimbursement rates for codes with modifier -59 attached vary by payer, expect half the normal reimbursement for codes with modifier -51 attached. (Most insurance companies have adopted Medicare's policy of paying 50 percent for codes with modifier -51 attached.)