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Urology Coding Alert

Modifier -59 Is Not Your License to Unbundle

Published on Fri Aug 01, 2003

Appending -59 (Distinct procedural service) to a code will essentially override a National Correct Coding Initiative (NCCI ) edit that indicates the service is bundled with another service. Using this modifier will usually result in payment for this bundled service. But carriers will often audit what they see as inappropriate reimbursement brought about by using modifier -59 and will request refunds.

"It is a very dangerous modifier because a lot of times people think of it as a license to unbundle," says Barbara Cobuzzi, MBA, CPC, ChBME, president of Cash Flow Solutions in Lakewood, N.J. "If you disagree with a bundle that is part of NCCI, using -59 because you're mad about the bundle isn't appropriate," Cobuzzi warns. "Yes, you can get paid, but should you? Can you defend modifier -59's use and defend that you weren't committing fraud?"

To test whether you're using -59 appropriately, ask yourself the following questions:

 1. Does the component second procedure represent a separate site of surgery?

 2. Did the component separate procedure occur during a separate session?

 3. Could I defend my use of modifier -59 to my peers?

 4. Does the physician documentation support using modifier -59?

 5. Does the NCCI allow me to use modifier -59?

If you answer "yes" to each of these questions, you're probably safe to append modifier -59. If not, think long and hard before putting that -59 on your claim.

A lot of the confusion about modifier -59 might come from the modifier indicators in NCCI, says consultant Cindy Parman, CPC, CPC-H, with Coding Strategies Inc. in Atlanta. If the status indicator is "0," that means the "modifier will not bypass [the] bundling edit," and a "1" means the "modifier is allowed and will bypass [the] edit," she says.

Lesson: That doesn't mean, however, that if the indicator is "1," you should use the modifier, Parman says. "When a code combination lists indicator '1,' it means that if the documentation supports a separately identifiable service [and the clinical circumstances meet the above criteria] then it is appropriate to apply modifier -59." But if the physician performed both services in the same session and one service "was integral to the other," you absolutely should not use modifier -59.

Think of -59 as the "modifier of last resort," Parman tells coders. Before using it, run through the other modifiers to see if a different one is more appropriate. "Examples would be      -76/-77 (Repeat procedure by same physician/Repeat procedure by another physician), -58 (Staged or related procedure or service by the same physician during the postoperative period) or -78/-79 (Return to the operating room for a related procedure during the postoperative period/Unrelated procedure or service by the same physician during the postoperative period)," she says.

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