Urology Coding Alert

Pointer: Correct your claims if you realize you have been doing it wrong.

Now that you have read about when you can and can't break the latest Correct Coding Initiative (CCI) bundles using a modifier in "Include I&D, Skin Suture Procedures With Your Urological Surgery Codes, Thanks to CCI 18.3", you should make sure you know how to properly use modifier 59 (Distinct procedural service) on your claims.

Payers are still scrutinizing submissions for separate and distinct services, thanks to the OIG's reported error rates relating to modifier 59 use. But you can avoid these coding errors and prevent possible paybacks by using these two tips.

Tip 1: Determine Separate Regions

Pull a sample of your modifier 59 submissions and verify that the claims properly represent a distinct procedural service. Fifteen percent of the OIG's audited claims using modifier 59 had procedures that weren't distinct because "they were performed at the same session, same anatomical site, and/or through the same incision," says Daniel R. Levinson, inspector general, in "Use of Modifier 59 to Bypass Medicare's Correct Coding Initiative Edits," an article posted on the OIG Web site www.oig.hhs.gov/oei/reports/oei-03-02-00771.pdf.

Rule of thumb: Make sure the physician is working in a separate body area before you use modifier 59.

Example: Your urologist performs a hand-assisted laparoscopic total nephroureterectomy with open distal intravesical ureterectomy and excision of a bladder cuff for a patient with a mid-ureteral transitional cell carcinoma. You report 50548 (Laparoscopy, surgical; nephrectomy with total ureterectomy) for the laparoscopic total nephroureterectomy and 50650 (Ureterectomy, with bladder cuff [separate procedure]) for the open distal ureterectomy and excision of the bladder cuff.

If you don't put modifier 59 on 50650 (to change it to 50650 -59) to bypass the bundling edit between 50548 and 50650, your payers will consider the ureterectomy part of the nephrectomy if they apply Medicare's bundling edits. To be paid for both procedures you may use modifier 59 because these procedures represent two separate procedures on two separate anatomical parts of the urinary tract. The intravesical ureterectomy is an open abdominal procedure that represents a separate and distinct operative incision/approach involving the lower urinary tract while the initial surgery is a laparoscopic total nephroureterectomy involving the kidney and retroperitoneal ureter, the upper urinary tract. Both procedures are needed to ensure the highest cure rate for this type of malignant tumor.

Tip 2: Put 59 on the Secondary Code

Notice how the example above includes appending modifier 59 to the secondary code (50650). The Correct Coding Initiative publishes a list of comprehensive/component edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations, experts say. Each edit consists of a column 1 and column 2 code.

Review: If you report the two codes of a CCI edit for the same beneficiary for the same date of service without an appropriate modifier, the carrier will only pay for the column 1 code. The payer may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit. Although appending the modifier to the column 2 code may seem elementary, the OIG found numerous application errors.

Close call: Your modifier 59 payment was almost restricted to adhering to the "59 on the second code" guideline. The OIG encouraged carriers to pay claims only when modifier 59 is appended to the secondary code, not the primary, but CMS responded that it lacks the technical ability to put in place such an edit. Such an edit would have rejected payment for the following claim:  

Example: A urologist does a cystoscopic examination and transurethral resection of a large bladder tumor (52240, Cystourethroscopy, with fulguration [including cyrosurgery or laser surgery] and/or resection of LARGE bladder tumor) located on the left lateral bladder wall and also performs a cystoscopic bladder biopsy (52204, Cystourethroscopy, with biopsy [s]) on the right side of the bladder.

You submit the coding:

• 52240-59
• 52204.

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (52240) instead of the component or column 2 code (52204).

Action: "If you notice that you have put modifier 59 on the wrong code, resubmit the claim," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

Your corrected claim should look like this:

• 52240
• 52204-59. 

Bonus: You can test your modifier 59 skills with examples from the CMS modifier 59 article available online at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads//modifier59.pdf.