Updated on: June 22, 2012

Modifier 59: The Devil is in the Details, Part 3

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Original story posted on: May 25, 2011

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 the final installment in this three-part series.

 

 

 

 

What is the best practice process for adding Modifier 59 in a Facility Setting?

 

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

 

Is it appropriate to hard code modifiers in the Chargemaster?

 

When I'm asked if it is appropriate to hard code modifiers in the chargemaster I generally say, "yes," but only in 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 may also choose to do this with facility E/M codes.  The key here is to educate relevant staff members and validate through audits correct application.

 

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

 

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 the situations where 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.

 

Is it appropriate to append Modifier 59 to an EKG when it was done on the same date as but in a separate room and for a different indicate reason than a stress test, two different reports are documented?

 

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 work up and separate orders were given for both.

 

CCI directs that EKGs are inherently a part of stress test and would not typically be reported together.  But in the example I'm using and because the CCI shows a modifier indicator of 1, Modifier 59 would be allowed.  If there were separate orders and medical necessity to support the services, then Modifier59 could be appended.  Be ready to support this decision with documentation.

 

Is there a best practice to Validate Payments Related to Using Modifier 59?

 

Best practice warrants validating all payments received not just those appended with Modifier 59.  However, to validate payment specifically with the use of the modifier, 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 would also 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.

 

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

 

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

 

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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