May 17, 2011

Modifier 59: The Devil is in the Details, Part 1

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EDITOR'S NOTE: A recent Webinar conducted by eduTrax®’s Paula Digby generated a considerable number of questions. So we asked Ms. Digby to write this three-part article because there’s so much to cover when reporting Modifier 59. Here is Part I.

 

Let me start by saying that I appreciate all of the comments and understand providers' cries for more information related to Modifier 59. I'll cover key areas where Modifier 59 is used and examples of appropriate and inappropriate use for several specialty areas. Most of the general guidelines we'll discuss apply to both physicians and facilities. If there is a differentiation, I will note it.  Now the questions and answers:

 

Q: What is the best practice process for adding Modifier 59 in a facility setting?

 

A: The coding staff typically appends modifiers safely. There are some instances during which modifiers are hardcoded in the chargemaster and individual charge entry staff is educated on the appropriate use of the charge codes.

 

 

Q: Is it appropriate to hard-code modifiers in the chargemaster?

 

A: When I'm asked if it is appropriate to hard-code modifiers in the chargemaster, I generally say "yes," but only for those instances when it's coupled with training for key staff. In the case of radiology or laboratory services, a strong argument can be made for hard-coding modifiers. You also may choose to do this with facility E/M codes. The key here is to educate relevant staff members and validate through audits that correct applications are being used.

 

 

Q: Can you provide a best practice scenario for validating modifiers prior to claim submission?

 

A: I have not seen a process that catches all errors, but it does reduce errors significantly to only allow HIM coders to append the modifiers. In situations in which the modifiers are hard-coded in the CDM, having HIM coders audit the record prior to submission (or training an individual to do so, at least until relevant staff are getting it right) is a good plan.

 

 

Q: Is it appropriate to append modifier 59 to an EKG when it was done on the same date but in a separate room and for a different indicated reason than a stress test, (if) two different reports are documented?

 

A: Here's an example that will help explain how Modifier 59 can be appended to an EKG: when an exercise stress test is performed the same day and the EKG was performed in a separate room by a different technician than the exercise stress test - and both were done for pre-op workup and separate orders were given for both. CCI directs that EKGs are inherent parts of stress tests and typically would not be reported together. But in the example I'm using, because the CCI shows a modifier indicator of one, Modifier 59 would be allowed. If there were separate orders and medical necessity to support the services, Modifier59 could be appended. Be ready to support this decision with documentation.

 

 

Q: Is there a best practice to validate payments related to using Modifier 59?

 

A: Best practice warrants validating all payments received, not just those appended with Modifier 59. However, to validate payment with the use of the modifier specifically, you would need a person trained to understand the specific payment nuances and NCCI edits (or have a software program that could do it). This person or entity also would need to understand payment nuances and contract language to make sure payments are accurate. There are many companies out there performing this function for providers and the government. An example is the RACs.

 

 

Q: Which is more appropriate to use in a lab: Modifier 59 or 91?

 

A: Use Modifier 91 when the procedure is a repeat procedure and Modifier 59 if bundling edit applies. Remember, Modifier 91 may not be used if there was a test or equipment malfunction, or just to validate original results. Modifier 91 is used when it is medically necessary to get several results over a period of time, or if multiple results are required.

 

 

The Importance of NCCI

 

NCCI, or the National Correct Coding Initiative, is a list of edits that identify when services should and should not be reported together. The list also gives us direction regarding modifiers that cause us to bypass the edits.

 



 

Not all modifiers impact bundling edits. Modifiers 25, 27, 58, 59, 78, 79 and 91 do have the ability to affect our bundling edits and cause services that otherwise would not be paid to get paid. Of these modifiers, Modifier 59 is the most widely used (and potentially overused), therefore representing a huge target for reviewers.

 

You must understand a few things about NCCI in order to properly understand Modifier 59. Integral to most procedures - meaning acts you may not report separately with Modifier 59 if done in conjunction with and for the purpose of completing a surgical procedure - are placement of urinary catheters such as foley catheters; local, topical, or regional anesthesia performed by the operating physician; and the introduction of IV access (CPT® 36000, 36400). This means that injections or infusions on the same claim will be bundled if not appended with Modifier 59.

 

According to NCCI and coding guidelines, there are some procedures and/or services that are considered inherent and therefore bundled.  Listed below are a few of the most common we see.

 

Basic Bundled Medical Services:

 

  • Cardiac stress, including EKG
  • Interpretation of EKG, including interpretation of cardiac rhythm
  • Determination of ankle/brachial Indices (requires upper and lower doppler; upper is not separately reported).

 

Basic Bundled Surgical Services:

 

  • "Scout"/drive-thru scope with other procedure, not reported (Modifier 59 is not allowed).
  • Cardiopulmonary monitoring included (Modifier 59 is not allowed; 93000-10, 93040-42, 94760-61, 94770).
  • Biopsy/excision of separate lesion (requires Modifier 59).
  • More extensive procedure based on immediately preceding diagnostic procedure (Modifier 58 is appropriate).
  • Multiple approaches on the same procedure (Modifier 59 is not allowed).
  • Converted procedure scope to open (Modifier 59 is not allowed, report completed procedure).

 

CPT® Nomenclature and NCCI

 

Procedures with the following wording are not separately reportable on the same date of service unless performed during separate encounters or at separate anatomical sites (Modifier 59 is required when these parameters are met):

 

  • "Simple" or "complex/complicated" (i.e. CPT®10060 reported with 10061)
  • "Limited" or "complete"
  • "Intermediate" or "comprehensive"
  • "Superficial" or "deep"
  • "Complete" or "incomplete"
  • "External" or "internal"

 

When Modifier 59 is Appropriately Appended in a Facility

 

Modifier 59 most commonly is applied and is warranted for services provided in the ED, observation and even for OP ancillary services such as lab and radiology. These are some of the most common outpatient services provided in our facilities. Modifier 59 has the stigma not only of being used inappropriately but also being left off entirely when it is appropriate to report. It would only take a few minutes for your billing department to review claims that have been caught in the system due to CCI edits. If you were to shadow a biller, I guarantee that he or she likely would find one of these edits inside of five minutes, maybe sooner. Typically, these services are rejected due to the lack of a modifier describing a situation that would allow payment for the circumstance. Many times billers append a modifier to get a claim paid and feel good about the accomplishment of "getting that one off their desk." While this may seem like a good idea at the time, it is one of the reasons modifier 59 has been targeted: it gets those line items paid but often is not supported by the associated claim documentation.

 

Common correct uses include:

 

  • Appending Modifier 59 to multiple "initial" injection and infusion codes when they were provided at separate access sites. If the "initial" codes were reported and all of the injections/infusions were performed through the same access site or stick, Modifier 59 would not be appropriate to report.

 



 

  • Appending Modifier 59 to injections and infusions reported as part of a radiological or surgical procedure occurring during the same encounter or date of service - when the procedures are in fact separate and not done for the specific purpose of injecting dye, anesthesia or another substance related to the radiological or surgical procedure.

 

  • Appending Modifier 59 to surgical procedures that are considered bundled but under the circumstances are allowed to be reported separately. This could be because the procedure was performed on a different body part or during a different encounter on the same date of service.

 

About the Author

 

Paula Digby, CCS, CPC, CPCI, is Senior Vice President, Chief Content Officer and Co-Founder
 of AlphaQuest, LLC and eduTrax, LLC.  Paula has been in healthcare for more than 21 years with experience in medical coding and billing, auditing, medical coding education and training. She works with healthcare organizations and physician practices to identify and rectify revenue capture and process issues that have the potential to paralyze the organization.  She also directs chart to bill audits on behalf of those organizations.  She has broad experience across multi-physician practice specialties in supervision, management, reimbursement and coding.  Paula works on various Department of Justice files as an expert coding resource.

 

Contact the Author

 

paula@edutrax.net

 

To comment on this article please go to editor@racmonitor.com

 

Tackling RACs by Knowing National and Local Coverage Rules

 

Resources:

 

For a list of the current edits for your provider type, please visit the CMS website:

http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage


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