May 23, 2011

Modifier 59: The Devil is in the Details, Part 2

By

pdigby100

EDITORIAL 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 II.

 

 

 

 

Common Scenarios of reporting Modifier 59 by Outpatient Department

 

Some of the most common services for which Modifier 59 is utilized in various outpatient departments are listed below. Of course, when two indicated services are reported together, documentation should support the appropriate use of the modifier. Modifier 59 should not always be appended in the situations listed below, but rather only when appropriate based on the circumstances. Listed first below are some of the basic caveats and commonly seen applications followed by services, arranged by department:

 

 

  • Modifier 59 is never appended to E/M codes for physicians or facilities as represented by the CPT nomenclature "Distinct Procedural Service."

 

  • Common surgical procedure edits require Modifier 59 when appropriate. This means the services must be distinct from one another, not performed for the same stated reason.

 

o   Procedure & EKG (93000, 93005, 93010)

o   Procedure & Injection/Infusion/ Hydration (96360-96376)

o   Procedure & Vein Access (36000), Venipuncture/Cutdown (36400-36425)

o   Procedure & Transfusion (36430-36450)

o   Procedure & Fluoroscopy (76000, 76001)

o   Procedure & U/S /CT/MRI Guidance (76942, 77012, 77021)

o   Procedure & Foley Cath (51702-51703)

o   Excision & Simple Repair (Skin Procedures)

 

The following sections address the use of Modifier 59 in various circumstances and departments.

 

 

Modifier 59 and Separate Procedures

 

"CMS does not allow separate reporting of a procedure designated as a "separate procedure" when it is performed at the same encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach," according to NCCI.

 

(Modifier 59 is only allowed if applied to separate anatomical locations or separate encounters.)

 

 

Modifier 59 and Anesthesia

 

  • Anesthesia by a surgeon is always bundled. Modifier 59 is not appropriate to report.

 

  • Modifier 59 also is not allowed under these circumstances:

 

o   01000-01999 w/procedure

o   64400-64530 w/procedure (nerve blocks)

 

  • When these services are provided as anesthesia components, Modifier 59 is not appropriate:

 

o   Vein Access (36000/36410)

o   Drug Administration

o   Injections/Infusions/Hydrations (96360-96376)

Cardiac Assessment (93000-93010, 93040-93042) If performed in a different encounter/same date or if it is unrelated to procedure, Modifier 59 is allowed.

 

(Conscious sedation is excluded from this edit if allowed by CPT.)

 

Modifier 59 and Skin Procedures

 

  • If I&D and excision, repair, destruction or removal is performed on same anatomical site during the same encounter, Modifier 59 is not appropriate.

 

o   If separate sites/encounters apply, Modifier 59 may be reported.

 

  • For multiple removal methods per one lesion, Modifier 59 is not appropriate.

 

o   For separate lesions/encounters, apply Modifier 59.

 

  • For multiple lesions in one excision area, Modifier 59 is not appropriate.

 

o   For separate excision sites/encounters, apply Modifier59.

 

  • For biopsy/excision of the same lesion, Modifier 59 is not appropriate.

 

o   For separate lesions/encounters, apply Modifier 59.

 


 

 

  • For biopsy used for immediate pathologic diagnosis and a decision to proceed to more extensive procedures based on pathologic findings, apply Modifier 58.

 

  • For paring/cutting benign hyperkeratotic lesions (11055-57) with nail debridement (11720-21) on the same finger adjacent to nail, Modifier 59 is not appropriate.

 

o   If there are separate sites/encounters, apply Modifier 59.

 

  • For multiple lesions in a one-path sample, Modifier 59 is not appropriate.

 

o   For separate samples, processed separately or during separate encounters, apply Modifier 59.

 

  • For simple repair of an excised lesion, Modifier59 is not appropriate.

 

o   For separate sites for excision/repair or a separate encounter, apply Modifier 59.

 

  • Benign lesions of < 0.5cm include all repairs (simple, interim or complex).

 

  • For destruction of benign/premalignant lesions and biopsy of skin lesion (11100), same lesion, Modifier59 is not appropriate.

 

o   For separate lesions/encounter, apply Modifier 59.

 

Modifier 59 and Musculoskeletal Procedures

 

  • If debridement is included in a procedure (except for open fracture/dislocation), Modifier 59 is not appropriate.

 

o   For separate anatomical sites/encounters, apply Modifier 59.

 

  • For tendon lengthening at upper arm/elbow (24305) and neuroplasty (64718) at ulnar nerve at elbow, Modifier 59 is not appropriate.

 

  • For transposition of ulnar nerve at elbow (64718-Same CPT), apply Modifier 59.

 

Modifier 59 and Spine Procedures

 

  • For intraoperative neurophysiology testing by the same physician who performed surgery (i.e. 95920), Modifier 59 is not appropriate.

 

  • For laminectomy-segment (i.e. 63047) or laminotomy-interspace (63030) at same level, Modifier 59 is not appropriate.

 

 

Modifier 59 and Sinus Procedures

 

 

  • For control of bleeding (30901) during a procedure, Modifier 59 is not appropriate.

 

o   Return to OR post op, apply Modifier 78.

 

o   If no return to OR, treatment not reported, Modifier 59 is not appropriate.

 

  • For diagnostic and surgical thoracoscopy, ipsilateral side of thorax (32601,02,05,06), Modifier 59 is not appropriate.

 

Modifier 59 and Cardiac Procedures

 

 

  • For epi-aortic U/S during CABG (76998) for vascular graft procurement portion of procedure, Modifier 59 is not appropriate.

 

o   For CABG placement (not graft procurement), apply Modifier 59.

 

  • For aneurysm repair w/ thromboendarterectomy at same site or for endarterectomy to insert graft, Modifier 59 is not appropriate.

 

o   For separate non-contiguous sites, apply Modifier 59.

o   For vascular occlusion in a different vessel, apply Modifier 59.

 


 

 

Modifier 59 and Endovascular Procedures

 

  • For diagnostic angiogram on same date of intravascular intervention, apply Modifier 59 if:
    • None was previously performed (same or different date);
    • It was medically necessary to repeat to further define anatomy; or
    • If repeating only a portion, apply Modifier 52.

 

Modifier 59 and Endoscopy

 

Fluoroscopy is inherent to all endoscopic procedures, therefore Modifier 59 is not appropriate.

 

 

When these procedures are performed in tandem with one another and the scope is the method of approach, Modifier 59 is not appropriate to report. The following list does not include all possible scope procedure options.

 

  • Laparoscopy
  • Hysteroscopy
  • Thoracoscopy
  • Arthroscopy
  • Esophagoscopy
  • Colonoscopy
  • GI Endoscopy
  • Laryngoscopy
  • Bronchoscopy
  • Cystourethroscopy

 

 

Modifier 59 and Radiology Services

 

 

  • For substandard films requiring repeat study on the same day, Modifier 59 is not appropriate.

 

o   For a change in the patient's condition, Modifier 59 may be appropriate.

 

o   For a different encounter on the same day for the same service, report total services, including total number of views (one code), or if no code exists to describe the number of views, Modifier 59 may be appropriate. "Minimum" views include all those over that amount.

 

  • For studies requiring contrast and injections/ infusions, same encounter/day, Modifier 59 is not appropriate unless unrelated (i.e. injection not used to administer contrast).

 

  • For CT& CTA/MRI/MRA in the same anatomic region, situational use of Modifier 59 is acceptable.

 

  • For separate encounters or for two separate and distinct studies on medical necessity (two distinct studies is uncommon), apply Modifier 59.

 

  • For CT/CTA (75571-74) of the heart & EKG (93000-10), rhythm ECG (93040-42), Modifier 59 is not appropriate.

 

Modifier 59 and Laboratory Services

 

  • For a repeated test during the same encounter/date of service, apply Modifier 91. This includes components of panel (i.e. CMP-80053 and total protein 84155).

 

o   It is not appropriate to confirm original results or to re-test due to problems with specimens or equipment.

 

  • For bundled tests, apply Modifier 59 when appropriate.

 

o   Col 1 code 80061 Lipid Panel (including calculated measurement - 82465)

o   Col 2 code 83721 LDL cholesterol; Direct Measurement

 

o   Triglyceride < 400, 83721 not Reported

o   Triglyceride > 400, apply Modifier 59 to 83721

 

o   For free thyroxine (84439) and total thyroxine (84436), or for total thyroxine w/thyroid binding ratio (84479), Modifier 59 is not appropriate.

 

o   For automated CBC w/automated diff (85025) or without auto diff (85027) and micro blood smear with manual diff (85007) or without manual diff (85008), Modifier 59 is not appropriate.

o   Auto hemogram with manual diff (report 85027, 85007).

o   Automated hemogram with automated and manual diff (report 85025 only, Modifier 59 is not appropriate).

 

o   For bone marrow biopsy and aspiration on same anatomical site, Modifier 59 is not appropriate.

o   For separate incisions/encounters, apply Modifier 59.

 


 

 

Modifier 59 and Injections/Infusions Services

 

 

  • For initial Infusion (96365) or hydration (96360)/IV push (96374), same encounter, same access site, Modifier 59 is not appropriate.

 

o   For separate access sites/encounters, apply Modifier 59.

 

  • For IV access (36000, 36410) and infusion/chemotherapy, Modifier 59 is not appropriate.

 

o   For separate access sites/encounters, apply Modifier 59.

 

  • For fluid to administer medication, Modifier 59 is not appropriate when tied to incidental service.

 

  • For injection/infusion/hydration related to a procedure, Modifier 59 is not appropriate.

 

Modifier 59 and Therapy (PT/OT) Services

 

 

Two therapy services may not be reported in same 15-minute time period except for supervised modalities (97010-97028) with other therapy services.

 

  • For two timed procedures (i.e. group and individual) performed in separate time increments, apply Modifier 59. The time calculation rules apply.

 

  • For re-evaluation (97002, 97004) and planned therapy during the same day/encounter, Modifier 59 is not appropriate.

 

o   For a change in the patient's condition causing medical necessity, apply Modifier 59.

 

  • For manual therapy, each 15 minutes (97140) and therapeutic activities, each 15 minutes (97530) performed during same 15 minutes, Modifier 59 is not appropriate.

 

o   For separate time periods/encounters, apply Modifier 59.

 

  • For physician-performed selective debridement (97597-98) and surgical debridement (11040-11044) performed during the same encounter or same date of service, Modifier 59 is not appropriate.

 

  • For facility OPPS, Modifier 59 can be applied if either of these two events occur:

 

o   Two separate and distinct wounds require treatment regardless of physician or encounters.

 

o   Same for CPT 97602: removal of devitalized tissue from wound(s).

 

 

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

 

 

 

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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