Question

One of the most common NCCI edit errors is the use of Modifier 59 and it is under scrutiny by the Office of Inspector General (OIG) and other payers. Read the CMS article on the use of Modifier 59 to understand how this modifier is used correctly. EQ: Pick one of the Modifier 59 edits in the article and describe how coders can avoid this NCCI edit. .

Answer 1

Ans.

Modifier 59

Modifier 59 identifies procedures or services that are not normally reported together. The full definition of modifier 59, again from the AMA's CPT 2012, is:”Distinct Procedural Service: 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 the 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.”

To appropriately use modifier 59, physicians should not use it on an E/M service code. When billing for an E/M service and a procedure that is not typically included in an E/M visit, or is not typically done on the same day, physicians should use the 59 modifier on the non-E/M service code.

Modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury.

It should also be used when an intravenous (IV) protocol calls for two separate IV sites. It will indicate the second initial injection, or when the patient has returned on the same date of service for a separately identifiable service.

Finally, modifier 59 should be used when no other existing modifier applies to distinguish appropriately billable services.

Modifier 59 and the NCCI edits

The National Correct Coding Initiative (NCCI) edits, built into the Medicare contractors' claims processing systems, control improper payment of Part B claims by disallowing co-billing of certain combinations of CPT codes. With the NCCI edits, the coding gets a bit trickier because CMS forces modifier 59 to operate in ways contrary to its original design.

For the NCCI edits, CMS recently clarified in a MedLearn Matters article (see sidebar on page 8) that the main purpose of modifier 59 is to “indicate that two or more procedures are performed at different anatomical sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationship of the two or more procedure codes.” This is different from the way CPT defines modifier 59.

In other words, a physician can use modifier 59 to bill the secondary, additional, or lesser procedure in an NCCI edit combination. If the edit shows indicator “1,” modifier 59 can be used to communicate to the payer that the two billed services or procedures were appropriately performed together in that circumstance, such that either of the following is true:

• The procedures were done at different anatomic sites on the same date or
• The procedures were done during different patient encounters, for the same patient, by the same physician, on the same date.

In this way, modifier 59 is essentially a tool to bypass or override the NCCI edit.

There are relatively few NCCI edits that involve E/M services, but here are two examples:

• If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with psychological testing (such as CPT code 96101), modifier 59 would be appended to the testing code.
• If the circumstance calls for a Level 3 established patient visit (CPT code 99213) to be billed with a demonstration of home monitoring of a patient's international normalized ratio (e.g., HCPCS code G0248), modifier 59 would be appended to the demonstration code.

The overall effect of modifiers is to alert the payer to acceptable deviations from the CPT coding rules. The modifiers will not be used on all claims; the popular wisdom is that modifier use will be the exception rather than the rule. But there will be times when a modifier is needed. In all cases, physicians should remember that the documentation must show that the two services were separate and distinct.

In this article, though, we’ll focus on the trickiest of them all, modifier 59.

The definition of the 59 modifier per the CPT manual is as follows:

Modifier 59: “Distinct Procedural Service” – Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, 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 physician. 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.

When to Use the 59 Modifier
The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body.

Unfortunately, many times it is used to prevent a service from being bundled or added in with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.

59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed, it should be used instead of the 59 modifier.

When using the 59 modifier to indicate a distinct and separate service, documentation should be in the patient’s medical file that substantiates that the services were performed separately. The insurance carrier may request to review the record to deem if the 59 modifier is being appropriately used before reimbursing the full amount for the modified CPT code.

It’s important to note that use of the 59 modifier does not require that there be a different or separate diagnosis code for each of the services billed. As such, simply using different diagnosis codes for each of the services performed does not support the use of the 59 modifier.

59 Modifier Examples
An example of appropriate use of the 59 modifier might be if a physical therapist performed both 97140 (manual therapy) and 97530 (therapeutic activity) in the same visit. Normally these procedures are considered inclusive.

If the 59 modifier is appended to either code, they will both be allowed on the claim separately. However, the 59 modifier should only be added if the two procedures are performed in distinctly separate 15 minute intervals. If the therapist performs the procedures simultaneously, then the 59 modifier should not be used.

Another example would be if the patient were having a nerve conduction study with CPT codes 95900 and 95903 being billed. If the two procedures are done on separate nerves, then the 59 modifier should be used to indicate that. If the codes were performed on the same nerve, then the 59 modifier should not be used.

The biller should never be the one to add the 59 modifier to a claim, even if she knows that billing the services without the modifier will result in bundling or a denial. The 59 modifier should only be added by the provider or by a coder who has access to the patient’s chart.

If you are the biller and you believe that the 59 modifier would be appropriate but was not indicated, you should go back to the provider to see if it was omitted by mistake. Don’t just add the modifier to the claim without substantial evidence that it is needed.

Misusing 59, or any other modifier, can cause a payer to deny your claim altogether. Avoid claim issues by making sure to always use it properly.