Wiki modifier 59

[Alice Marshall]

I billled 45385 and 43239 together to Care Improvement Plus. They reviewed the charge and state that it was billed incorrected due to no modifier. The letter they sent suggested putting a 59 on the 43239. Since these are different anatomic sites I saw no reason to append the 59. What should I do?

 

[coachlang3]

Try a 51 modifier-mutliple procedures

 

[GaPeach77]

They are correct. A 59 modifier would be used if there are two different anatomic sites. A 51 modifier would be used if multiple procedures are used in one anatomic sites. The 51 modifier allows for reduction of the second procedure.

 

[mitchellde]

They are correct. A 59 modifier would be used if there are two different anatomic sites. A 51 modifier would be used if multiple procedures are used in one anatomic sites. The 51 modifier allows for reduction of the second procedure.

That is not correct on the definition and use of the modifiers. These two codes need no modifier to make them distinct from each other (59) as by descriptor and definition they are already as distinct as they need to be, however some payers still want you to indicate that the two procedures were accomplished in the same setting(51).
The 59 modifier is use to distinguish when two procedures are distinct and separate from one another when they would otherwise be bundled together.
The 51 tells the payer that the second and subsequent procedures were performed in the same procedural session for multiple procedure discounting.

 

[GaPeach77]

Debra, in your hurry to say that I am incorrect, you only repeated what I said. Maybe you did not understand fully my description of it. I repeat, the insurance carrier is correct that a 59 modifier would need to be added according to correct coding guidelines along with CMS's guidelines on proper usage of the 59 modifier. I have been auditing for many years, this has never changed, it only confuses many coders. Either the insurance carrier, CMS, and Encoder Pro are wrong, or you stand corrected.

 

[mitchellde]

for this combination you do not need the 59 to indicate distinct and separate as the code descri0tor already states this. If the carrier is wanting a modifier it could only be the 51 to indicate multiple procedures in the same procedural session. This is not what you stated.

Addendum:
There is no CCI edit for these two codes

 

[GaPeach77]

Debra,
That is incorrect. The endoscopy and colonscopy are two different organs and two different anatomical sites. As I mentioned earlier, a 59 modifier would be the correct modifier according to coding guidelines.
Why would you use a 51 modifier and get a reduced pricing rate when the carrier is stating that they will pay both procedures at 100% if you use the 59 instead? It may be beneficial to you to do a little research on your own about the difference between distinct and mulitple procedures, you appear to be a little confused on this issue.

ENCODER PRO: DEFINITION OF 59 MODIFIER

"Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25"

 

[mitchellde]

Debra,
That is incorrect. The endoscopy and colonscopy are two different organs and two different anatomical sites. As I mentioned earlier, a 59 modifier would be the correct modifier according to coding guidelines.
Why would you use a 51 modifier and get a reduced pricing rate when the carrier is stating that they will pay both procedures at 100% if you use the 59 instead? It may be beneficial to you to do a little research on your own about the difference between distinct and mulitple procedures, you appear to be a little confused on this issue.

ENCODER PRO: DEFINITION OF 59 MODIFIER

"Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25"

I understand the definition of the 59, it will not make the procedures pay at 100%. It is not needed for this paring as these two procedure are normally performed together and need no separation as they are already descriptive for separate organ. They are normally performed in the same session and that is why the 51 modifier is still wanted by some payers.
Your earlier definition of the 59 and 51 is still incorrect, you do not use the 59 to indicate different organ and the 51 to indicate multiple sites of the same organ. That is what I was correcting
Also there is no need for a modifier with this pair beyond the 51.

 

[GaPeach77]

Debra,

A 51 is used for as it's stated-multiple surgeries. The two codes in question are -oscopies not surgeries. The endoscopy and colonoscopy are considered procedures per use of correct modifier application. As I posted, the use of 59 by anatomical site is not my definition but the definition of Encoder Pro. I don't know what your definition of distinct procedural service is because you have not define one, I will stick with coding guidelines and Encoder Pro's definition of a distinct service as stated in my last post. I could hardly drop that and pick up your interpretation or definition when you have failed to state one. Also, the 51 modifier does reflect the multiple surgery pricing reduction with most payers. Let me add, that if you use the 59 modifier and a payer does not reimburse at 100% of the contracted rate, then that decision should be appealed.

 

[Alice Marshall]

Wow, what a good debate! But I still don't know what to do.

I went to the Nashville Regional Conference and the speaker from Yale agrees that no modifier is needed because the description itself is sufficient. The difference may be that one of you debating may be a hospital coder and the other from a physician's office. If I put a 59 on the EGD that means I'm asking for full payment. So they probably owe me money! But after a phone call from Care improvement plus they said just to do what the leter says. I am going to send it with a letter of why I still disagree with them. Coding is never easy! Thanks for your input. Much appreciated

 

[coachlang3]

simonewill7,

I don't have any thing to back me up per se. But it is common knowledge in the coding industry that the 59 modifier is called the "unbundler". You only use that modifier when two CPT codes are intrinsically connected. Such as a 45385 and a 45380. Then you must have two seperate anatomical sites of the colon (sigmoid and transverse for example) to show those two seperate sights.

And if you look in the CPT book a 51 modifier states "multiple procedures" not "multiple surgeries".

It also why a couple of years ago Medicare came out and told us to stop putting the 51 modifier on the EGD's when there was also a colon as their software does it automatically and it was messing up the claims.

Now you can use encoder pro all you want when it comes to modifiers but if it states surgeries for 51, I'm going to keep looking at the AMA, the one's who create the CPT's and know what goes with what.

To add to it, United Healthcare has told the practice I work for to use a 51 on the EGD if there is a colon done and to use the 59 if there was more than one colon (or EGD) procedure done (ie 45380 and 45385) doesn't even matter if there is an CCI or not for bundling.

Example:

pt 1
45385
45380 (59 mod)
43239 (51 mod)

pt 2

45384
43248 (51 mod)

 

[GaPeach77]

simonewill7,

I don't have any thing to back me up per se. But it is common knowledge in the coding industry that the 59 modifier is called the "unbundler". You only use that modifier when two CPT codes are intrinsically connected. Such as a 45385 and a 45380. Then you must have two seperate anatomical sites of the colon (sigmoid and transverse for example) to show those two seperate sights.

And if you look in the CPT book a 51 modifier states "multiple procedures" not "multiple surgeries".

It also why a couple of years ago Medicare came out and told us to stop putting the 51 modifier on the EGD's when there was also a colon as their software does it automatically and it was messing up the claims.

Now you can use encoder pro all you want when it comes to modifiers but if it states surgeries for 51, I'm going to keep looking at the AMA, the one's who create the CPT's and know what goes with what.

To add to it, United Healthcare has told the practice I work for to use a 51 on the EGD if there is a colon done and to use the 59 if there was more than one colon (or EGD) procedure done (ie 45380 and 45385) doesn't even matter if there is an CCI or not for bundling.

Example:

pt 1
45385
45380 (59 mod)
43239 (51 mod)

pt 2

45384
43248 (51 mod)

I have never heard of only using the 59 modifier if two codes are "intrinsically connected." I cannot find any information from the AMA or etc that supports that theory.
As far as Encoder Pro versus AMA, you will not find much contradiction between the two, and a good coder uses all the resources they can get. Don't limit yourself.

 

[mitchellde]

Debra,

A 51 is used for as it's stated-multiple surgeries. The two codes in question are -oscopies not surgeries. The endoscopy and colonoscopy are considered procedures per use of correct modifier application. As I posted, the use of 59 by anatomical site is not my definition but the definition of Encoder Pro. I don't know what your definition of distinct procedural service is because you have not define one, I will stick with coding guidelines and Encoder Pro's definition of a distinct service as stated in my last post. I could hardly drop that and pick up your interpretation or definition when you have failed to state one. Also, the 51 modifier does reflect the multiple surgery pricing reduction with most payers. Let me add, that if you use the 59 modifier and a payer does not reimburse at 100% of the contracted rate, then that decision should be appealed.

OK let me try again, I have stated the definition of the 59 but let me be more clear, the 59 modifier is used to indicate when the second procedure needs distinction as being separate and not a part of the preceding procedure. When the procedure definition is already clear regarding the site or organ involved and is already distinct and separate then you need no modifier to say this again, it would be redundant. As in if there were only one endoscopy code and we used that one code for all endoscopies then a 59 would be needed to indicate a separate orifice involved. But since the EGD is inserted via the oral orifice and the colonoscopy is inserted via the anal orifice, there is no need to communicate that these are distinct. You could never examine the esophagus via the anal orifice so this is not in question. However if you performed a biopsy of the transverse colon and another in the ascending colon then yes you need a 59 to distinguish the two procedures as distinct and separate since the code does not distinguish between the different parts of the colon. The endoscopies are suppose to be paid at 100% it is not the modifier that does this.
If you had 2 lesions on the trunk you would use the 59 to distinguish the second one as a distinct and separate site and it would be reduced at 50%
The CPT book section 10000 thru 69999 is the surgical section of the book, the word surgery and procedure are in fact interchangeable terms.

 

[mitchellde]

I went to the Nashville Regional Conference and the speaker from Yale agrees that no modifier is needed because the description itself is sufficient. The difference may be that one of you debating may be a hospital coder and the other from a physician's office. If I put a 59 on the EGD that means I'm asking for full payment. So they probably owe me money! But after a phone call from Care improvement plus they said just to do what the leter says. I am going to send it with a letter of why I still disagree with them. Coding is never easy! Thanks for your input. Much appreciated

You should explain to them why this particular pair does not require the use of the 59. There is no need to indicate with a modifier what is already indicated by the code itself. If it is not obvious that these procedures are not distinct by nature then you explain that an examination of the esophagus can never be accomplished via the anal orifice. I have used this many times and payers have fixed the edit as a result.

 

[GaPeach77]

OK let me try again, I have stated the definition of the 59 but let me be more clear, the 59 modifier is used to indicate when the second procedure needs distinction as being separate and not a part of the preceding procedure. When the procedure definition is already clear regarding the site or organ involved and is already distinct and separate then you need no modifier to say this again, it would be redundant. As in if there were only one endoscopy code and we used that one code for all endoscopies then a 59 would be needed to indicate a separate orifice involved. But since the EGD is inserted via the oral orifice and the colonoscopy is inserted via the anal orifice, there is no need to communicate that these are distinct. You could never examine the esophagus via the anal orifice so this is not in question. However if you performed a biopsy of the transverse colon and another in the ascending colon then yes you need a 59 to distinguish the two procedures as distinct and separate since the code does not distinguish between the different parts of the colon. The endoscopies are suppose to be paid at 100% it is not the modifier that does this.
If you had 2 lesions on the trunk you would use the 59 to distinguish the second one as a distinct and separate site and it would be reduced at 50%
The CPT book section 10000 thru 69999 is the surgical section of the book, the word surgery and procedure are in fact interchangeable terms.

Your earlier post did not state that.

You posted, "That is not correct on the definition and use of the modifiers. These two codes need no modifier to make them distinct from each other (59) as by descriptor and definition they are already as distinct as they need to be, however some payers still want you to indicate that the two procedures were accomplished in the same setting(51).
The 59 modifier is use to distinguish when two procedures are distinct and separate from one another when they would otherwise be bundled together"

The trunk area of the body is one anatomical site therefore removal of lesions would need a 51 modifier or whatever the payer requested. I don't understand the advice of appealing as opposed to just using the requested modifier from the payer and getting the claim paid. Sounds like shaky advice to me. Many coders use payer fee schedules when coding and apply the requested modifier to the procedure the first time around in order to submit a clean claim and get reimbursed properly opposed to the run of the mill. That in my opinion would have been more seasoned advice.

 

[coachlang3]

"Intrinsically connected" are my words. Intrinsic means built-in, part of,etc.

Hence when you do a 45385 and you do a 45380 you need to add a modifier for the payor to understand they are seperate and should not be bundled together. Normally those two would be considered the same thing (or intrinsic to each other) just different techniques of removal.

And I do not limit myself to one resource (I even have a sub to encoder pro). But I put more trust in the people and organization that creates the codes we use to tell me the correct definition of a code or modifier.

 

[coachlang3]

I don't understand the advice of appealing and opposed to using the requested modifier from the payer and getting the claim paid by just resubmitting the requested modifier. Sounds like shaky advice to me. As far as CPT codes as descriptors, none of the codes are the same. I dont understand that argument at all.

Because that letter was sent with the thought that maybe a 59 would be appropriate. Who sent the letter and what are their credentials to be sending it? So you send the claim back with a 59 and get paid. And then a month or two or more, after an audit is done, by someone who is credentialed at the payors office, then says this wasn't paid correctly and then you have to return all of the money and waste time getting the claim fixed and resubmitted and repaid or they deny it as beyond timely filing because you might have to submit an entirely new claim. And you still waste the time and more. That's why you take the time and effort to do the appeal right the first time.

 

[mitchellde]

Your earlier post did not state that.

You posted, "That is not correct on the definition and use of the modifiers. These two codes need no modifier to make them distinct from each other (59) as by descriptor and definition they are already as distinct as they need to be, however some payers still want you to indicate that the two procedures were accomplished in the same setting(51).
The 59 modifier is use to distinguish when two procedures are distinct and separate from one another when they would otherwise be bundled together"

The trunk area of the body is one anatomical site therefore removal of lesions would need a 51 modifier or whatever the payer requested. I don't understand the advice of appealing as opposed to just using the requested modifier from the payer and getting the claim paid. Sounds like shaky advice to me. Many coders use payer fee schedules when coding and apply the requested modifier to the procedure the first time around in order to submit a clean claim and get reimbursed properly opposed to the run of the mill. That in my opinion would have been more seasoned advice.

I have now said the same thing as many ways as I can and the meaning is still the same, If you have 2 lesions on the trunk and you apply only the 51 modifier then one will denied as inclusive to other due to the CCi edit for component of comprehensive if one is larger than the other or duplicate line if they are the same code, you must have the 59 modifier to indicate distinct and separate site for the second or smaller excision the 51 only states you performed 2 at the same session. So if the provider performed a small excision but then decided at the same session that he really needed to take a bigger piece and followed with a larger excision of the same site, while the op note may read as 2 excisions were performed they would be bundled, and a 51 would make them remain bundled, you would be unable to unbundle and can bill only for the larger. But if there were in fact 2 separate areas excisied in the same anatomic region then you would use the 59 modifier to express to the payer that these were not 2 excisions of the same site but rather 2 distinct and separate sites.
Now a 51 can be applied also as the second modifier but most payers now consider this to be redundant and do no longer want the 51 used.
Now all of this is consistent with the definition you posted regarding usage of the 59, you are not reading the definition correctly and I am not sure how to advise further. The 59 modifier will not stop discounting where discounting is suppose to occur.

 

[mitchellde]

Because that letter was sent with the thought that maybe a 59 would be appropriate. Who sent the letter and what are their credentials to be sending it? So you send the claim back with a 59 and get paid. And then a month or two or more, after an audit is done, by someone who is credentialed at the payors office, then says this wasn't paid correctly and then you have to return all of the money and waste time getting the claim fixed and resubmitted and repaid or they deny it as beyond timely filing because you might have to submit an entirely new claim. And you still waste the time and more. That's why you take the time and effort to do the appeal right the first time.

well put! the payer cannot tell you how to bill a claim nor a specific line item, they state maybe a 59 as a suggestion but not limited to. We do not code for the payer, we code for the documentation and apply correct coding guidelines and rules and regulations.

 

[ollielooya]

These lively debates are a great learning experience

Thanks to those involved not only in this thread but others that are ongoing at this point in time. I cannot believe the disparity in understanding the use of modifier 59 and 51, and I personally struggle at times in knowing which one should be used. It seems many coders, (new and seasoned veterans) wrestle with proper use and application. Furthermore, I'm still grappling with the interpretation of modifier 50 by some payers. I also had a payer tell us to add modifier 50 to an add on code to a procedure that was denied. I disagreed but admittedly did consider their suggestion to get the line item paid. But Coachlang's and Debra's followup validated my first reaction, so will navigate the process as outlined.

I learn so much from these spirited discussions and rebuttals. No doubt others feel the same way?
---Suzanne E. Byrum CPC