Urology Coding Alert

Myth: Always use 59 to unbundle same-session, different-reason procedures

If you always apply modifier 59 and unbundle two procedures that the Correct Coding Initiative (CCI) bundles when a physician performs them during the same session but for different reasons, you had better rethink your modifier use.

You can apply modifier 59 (Distinct procedural service) only if your urologist performed the normally bundled procedures during different sessions, in different anatomical areas or if they were otherwise totally unrelated.

The bottom line: Missing the mark on modifier 59 is sure to get you in trouble with auditors.

Prepare for Greater Scrutiny

Many providers and coders believe they can use modifier 59 as long as they have different diagnoses or reasons for the procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City. This is a no-no, and the HHS Office of Inspector General (OIG) has warned against this sort of inappropriate overuse.

Why: Medicare estimates that it could save $538 million by reducing improper use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and $59 million by cutting back on inappropriate modifier 59 use, the HHS Office of Inspector General insists in its 2007 compendium of unimplemented recommendations.

What it means to you: Expect your carriers to scrutinize your modifier 59 claims and to request documentation to support proper modifier use.

Look at Other Modifiers First

CPT's modifier 59 guidelines say that if another modifier is appropriate, such as if it defines the site of the procedure better, you should use it instead of modifier 59, Cobuzzi says. For example, you should use modifiers LT (Left side) and RT (Right side) to indicate anatomic location.

Example: A urologist performs a bilateral partial nephrectomy for bilateral small renal cell carcinomas. Per CPT and CCI rules, you cannot use modifier 50 (Bilateral procedure) with 50240 (Nephrectomy, partial). You might consider reporting this bilateral surgery scenario using modifier 59: 50240 and 50240-59. But the better coding choice would be 50240-LT and 50240-RT, coding experts say.

Unfortunately, many payers, including some Medicare carriers, have a hard time recognizing these modifiers, so you may end up having to use modifier 59 after all with those carriers. Similarly, Medicare is supposed to pay for multiple units of lesion removal codes, but with some carriers you may have to bill the same code multiple times using modifier 59 instead. 

Turn to 59 for Separate Sessions

Bottom line: You may use modifier 59 for two separate sessions during which the physician provides services that are normally bundled when done during a single patient encounter, Cobuzzi says.

Example: Your urologist performs bladder instillation of mitomycin after a patient has left the operating room after a transurethral resection of a bladder tumor (TURB)--that is, the instillation occurred in the recovery room or on the hospital floor. For the TURB, you'll report 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]). You may report 51720 (Bladder instillation of anticarcinogenic agent [including retention time]) for the instillation.

Append modifier 59 (Distinct procedural service) to 51720 to indicate that the instillation occurred later on the same day and at another location (not in the operating room but in the recovery room or at the bedside) and during another encounter.

Note: Also remember that to be paid, the operating surgeon (not a resident, nurse or physician assistant) must perform the instillation.

Caution: If the urologist performed the instillation immediately after surgery in the operating room, your carrier (and CCI edits) considers the instillation part of the complete operative procedure and not a separately billable service.