Thomas.
Thanks for the response.
I have to partially agree and disagree on many points.
Many carriers, including CMS
limit modifier 59 to
bundled pairs in the NCCI listing.
A lot changed for “Medicare” starting in 2013.
As of July 2013, modifier 59 can only be used to unbundle codes relative to the National Correct Coding Initiative listings which appear as
code pairs.
Source:
https://www.aad.org/File%20Library/Unassigned/DCC_Fall_2013.pdf
“Q. I just received a Medicare denial as duplicate procedure when billing for two excisions, 11401 listed on two separate claim lines, one with Modifier 59. What’s wrong?
A. Effective July 1, 2013, Modifier 59 can only be used, when medically necessary, to unbundle a procedure code that has been bundled related to the National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two or more times for the same date of service, should be submitted with an appropriate repeat procedure modifier. Rather than Modifier 59, Modifier 76 should be used to report a service or procedure that was repeated by the same practitioner subsequent to the original service or procedure. If multiple same lab or pathology services are reported, Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient.”
Many carriers consider the use of modifier 59 inappropriate if they do not appear as a bundled pair in the NCCI listings. A code is never bundled with itself or appearing as a code pair in the NCCI listings.
For example.. here is WPS Medicare’s policy on modifier 59…
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-59
“
Inappropriate Usage
Code combination
not appearing in the NCCI edits”
Modifier 76
Dermatologists use modifier 76 for “like” or repeat surgical proceduures (when not billable in units) for DECADES. It’s been taught this way by the American Academy of Dermatology and coding experts for ever. Most carriers accept modifier 76 for repeat surgical procedures without question. There are a few that don’t recognize modifier 76 on surgical procedures. For those carriers, you bill without 76 and add an instruction in box 19.
Example… WPS Medicare is one of the odd-balls that doesn’t recognize modifier 76 for repeat “surgical procedures”. Rather than use modifier 59 (which they say is incorrect two identical codes don’t appear together in the CCI, they say omit a modifier all together and use Box 19 to indicate the repeat procedure.
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-76
Additional sources of information from the AAD on the acceptable use of modifier 76…
Top-right of page 6…
https://www.aad.org/File Library/Ma...sources/Derm Coding Consult/DCC_Fall-2014.pdf
Right-side or page 4…
https://www.aad.org/File Library/Ma...programs/Publications/DCC/DCC_Spring_2015.pdf
Yes, there are are a bunch of carriers that will prefer modifier 59(XS) instead of 76. The inconsistencies are frustrating.
I know we’re talking about UnitedHealthcare here...
My original post shows that UHC does indeed recognize modifier 76 for repeat (or like) surgical procedures. They pay without issue or appeal in my example (and many, many surgical procedures). I see it on EOBs all the time.
They also, or course, pay with modifier 79 for unrelated services within a global period.
They have an issue when combined on the same line. Usually several appeals will resolve the issue.
So I was hoping someone can show me a better way (verification with an EOB would be even better).
Regarding modifier 59/XS as the way, I have issues in regards to
UHC…
UHC published their
CCI Editing Policy referencing modifier 59 as of late 2016. It gives a starting point for an argument.
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/CCI_2017A.pdf
Here is UHC’s
Rebundling policy stating that they follow Medicare’s NCCI guidelines
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/Rebundling_2016A.pdf
11401 and 11401 don’t appear anywhere together in column I and column II
So my argument is that modifer 59 or XS for a repeat or “like” surgical procedure goes against the CMS guidelines for the NCCI which state that only codes that appear in the NCCI listings as bundled pairs can appropriately be used with modifier 59.
Again, appeals (sometimes multiple) will fix this.
I know this is an unusual situation, but I think the use of both modifiers as acceptable with UHC is proven. The combination causes a system failure.
Thanks again, Thomas for your input. Much appreciated.
Anyone else have suggestions or thoughts?