Urology Coding Alert

Use this checklist to help avoid denials and audits

You know -- and so do payers and auditors -- that modifier 59 (Distinct procedural service) is on the watch list for potential abuse. But that doesn't mean that you should avoid the modifier altogether.

You'll use modifier 59 when your urologist performs procedures that you would not usually report together (that is, they're bundled) but that under certain circumstances are appropriate to report together, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis. According to CPT and the national Correct Coding Initiative (CCI), these circumstances are:

• different sessions or patient encounter

• different procedure or surgery

• different site or organ system

• separate incision/excision

• separate lesion

• separate injury (or area of injury in extensive injuries).

Warning: Even if documentation supports a separate site, excision, patient encounter, etc., you may not be able to override a CCI edit using modifier 59, Hause says. First, you must check the CCI modifier indicator for the bundled code pair you wish to report. Each CCI code-pair edit includes a correct coding modifier indicator of "0" or "1."

A "0" indicator means that you may not unbundle the edit combination under any circumstances, whereas a "1" indicator means that you may use a modifier to override the edit if the procedures are distinct from one another (but only if the procedures also meet any of the conditions for modifier 59 use outlined above), Hause says.

For more info: To learn more about modifier 59, sign up for the audioconference "Modifiers 25 and 59 Best Practices That Keep Your Claims in the Clear," on Feb. 26 at 11 a.m. EST. Visit http://www.audioeducator.com/industry_conference.php?id=856 or call (800) 508-2582.