Hi all,
Can someone please explain to me when the 36215/36245 code sets need either -51 or -59 modifiers? I was told once that these codes always need a -59, but then someone else said that's not right. Do they ever get -51's?
I notice on my Medicare remits that they sometimes put these codes in parenthesis with no modifiers...does that mean I don't need them? HELP!
Thank you!!
~Amy
Hi Amy,
Modifier -59 is used to identify procedures/services that are not normally reported together, but appropriate under certain circumstances. Documentation must support a different session, procedure/surgery, different site or organ system. Mod -59 is a high-risk issue and needs to be used in extreme care as it is high on the list of RAC.
*A question for you first, are you coding for hospital inpatient or outpatient? If hospital inpatient, then no modifiers are needed because Medicare reimbursement is driven by DRG. Based on what you mention on your MCR remit, they are obviously not requiring you to submit the -59. Every MAC is different based on geographical location.
*Regarding -51. This modifier is not approved for Ambulatory Surgery Center
(ASC) Hospital Outpatient Use. I do believe the -59 is for professional coding/billing only (I think).
*I will give you examples of mod -59 regarding 36215 & 36245, first order vessels, in scenarios from my own experience. Our in-house edit system does not recognize vascular order, so in that case I have to add -59 when appropriate upon submitting to Medicare.
HEAD & NECK:
Ex #1: Radiologist selects Rt brachiocephalic innominate artery and Lt Sublcavian
artery. Codes= 36215,Rt & 36215,Lt. It is important to clarify Rt & Lt especially in head studies because the anatomy is not parallel on both sides. No -59 needed here because Rt & Lt are clarified.
Ex#2 Rad selects Lt Subclavian and moves catheter and selects Lt Common Carotid. Codes= 36215-Lt & 36215-59, Lt. The -59 is needed here because two 1st order vessels on the same side. were selected and the -59 clarifies that a different vessel was selected.
Ex#3 Catheter in arch w/study, bilateral common carotids w/studies:
The Rt common is assigned 36216. The Lt common carotid, in a different arterial family, is assigned 36215. The code set for this example is: 36216, 36215-59
_______________________________________________________________
Abdomen:
Ex#1: Catheter in superior mesenteric(sma) and Lt & Rt arteries, with injections and studies in each vessel.
CODES: 36245,36245-59,(or 36245 x3 depending on payor guidelines), 75726(sma), 75724(bilateral renals).
Ex#2: Catheter in celiac axis, left gastric, common hepatic, left renal and right renal artery. Injection and imaging in each vessel.
CODES: 36246(lt gastric), 36248(common hepatic), 36245-59(right renal),36245-59(left renal), 75726(celiac), 75774(gastric), 75774-59(hepatic), 75724(renals).
Hope this helps!
Best Regards,
CSwift CPC, CPC-H