Look for a Separate Location or Session Before You Append 59

Ambulatory Coding & Payment Report 2008: Volume 13, Number 2

Payers know that modifier 59 is ripe for abuse, and over and again 59 comes under increased scrutiny from Medicare, the HHS Office of Inspector General (OIG) and others. With this year’s revision to CPT guidelines outlining the appropriate use of modifier 59, now’s the time to ensure your own claims meet the standard by following these four expert-approved tips.

1. Recognize When 59 Applies

You may use modifier 59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure the physician provides on the same date, says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh and past member of the AAPC national advisory board.

Specifically, CPT -- backed by guidelines in Chapter 1 of the national Correct Coding Initiative -- instructs that you may append modifier 59 when your surgeon:

• sees a patient during a different session
• treats a different site or organ system
• makes a separate incision/excision
• tends to a different lesion
• treats a separate injury.

Example: The surgeon performs a single lesion excision near the right wrist, along with lesion excision followed by adjacent tissue transfer at another location near the elbow.

In this case, you should report the lesion excision followed by adjacent tissue transfer near the elbow using the appropriate tissue transfer code only (for example, 14021, Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm).

You may report the lesion excision in a separate location using the appropriate lesion excision code (for example, 11601, Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.6 to 1.0 cm) with modifier 59 appended.

Although CCI bundles lesion excisions (11400-11646) to adjacent tissue transfers (14000-14350), in this case the tissue transfer (near the elbow) and excision (near the wrist) are in separate locations. You may report both codes, but to indicate the excision’s separate nature (and to override the CCI edit), you must append modifier 59 to 11601 and provide supporting documentation to justify the claim.

Reminder: CPT indicates that you should not use modifier 59 if another, more specific modifier describes the situation better (such as modifier 58, Staged or related procedure or service by the same physician during the postoperative period). In addition, you should never append modifier 59 to any E/M service code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC.

2. Look to CCI for Bundles, Options

If you have any doubt that two procedures are subject to bundling edits, simply check the CCI. If the CCI lists any two codes as “mutually exclusive” or pairs them together as “column 1” and “column 2” codes, you know the procedures are bundled, and you would not normally report them together.

Note: All procedures that CPT identifies as “separate procedures” will be subject to extensive bundles by CCI, Cobuzzi says.

Learn when to unbundle: Even if documentation supports a separate site, excision, patient encounter, etc., however, you may not be able to override a CCI edit using modifier 59. First, you must check the CCI correct coding modifier indicator for the bundled code pair you wish to report.

Here’s how: Each CCI code-pair edit includes a correct coding modifier indicator of “0” or “1.” You can find the correct coding modifier as a superscript placed to the right of the column 2 code in each bundled code pair.

A “0” indicator means that you may not unbundle the edit combination under any circumstances, according to CCI guidelines.

A “1” indicator means that you may use a modifier to override the edit if the procedures are distinct from one another (but only if the procedures also meet any of the conditions for modifier 59 use outlined above).

Example: CCI bundles 37785 (Ligation, division and/or excision of varicose vein cluster[s], one leg) into 37718 (Ligation, division and stripping, short saphenous vein). This means that the surgeon cannot report ligation of secondary varicose veins (37785) for the same short saphenous vein(s) that he strips (37718) because this would represent double-billing.

But CCI assigns a “1” modifier indicator to the edit bundling 37785 and 37718. Therefore, if the surgeon performs ligation of different secondary veins (that is, those not associated with the short saphenous vein stripping performed during the same session), you may claim 37785-59 in addition to 37718 to differentiate between the services provided at different times or (as in this case) at different locations on the body.

Tip: You should link an appropriate diagnosis to each code, and your documentation should support 37785’s independent nature (that is, the documentation should clearly state that the procedures occurred at different anatomic locations).

3. Always Attach 59 to the ‘Secondary’ Code

When you append modifier 59 to break a CCI edit, or bill separately for a CPT-described “separate procedure,” you should always append the modifier to the component/column

2 or “separate procedure” code.

Example: In the above case of the surgeon coding separately for stripping the short saphenous vein (37718) and secondary varicose veins (37785), 37718 represents the column 1, or more extensive, procedure. Therefore, as demonstrated, you must append modifier 59 to 37785, which is the secondary or column 2 code.
Remember this: The order in which the physician performs the procedures doesn’t determine which code receives modifier 59, Hvizdash says.

4. Never Unbundle Without Cause

Append modifier 59 to a claim only if you are certain of the involved procedures’ distinct nature, and never simply to override CCI bundles and get paid, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash. The Office of Inspector General knows that modifier 59 is ripe for abuse, and keeps an eye out for inappropriate claims.

Coding example: The CCI bundles a colonoscopy with biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to the colonoscopy with removal by hot biopsy forceps (45384, … with removal of tumor[s], polyp[s] or other lesion[s] by hot biopsy forceps or bipolar cautery) or by snare technique (45385, … with removal of tumor[s], polyp[s] or other lesion[s] by snare technique).

Proper unbundling: The physician biopsies one lesion and removes a separate lesion. Report the biopsy with 45380 and the separate lesion removal with 45384 or 45385, based on the technique the surgeon uses. Because the removal code is the higher-valued procedure, you should append modifier 59 to the biopsy (45380) and include documentation that clearly states that the biopsy and removal(s) occurred at different sites.

Improper unbundling: The surgeon biopsies and removes a single lesion. In this case, the procedures would not qualify as “distinct procedural services,” and you should code the removal only.

Bottom line: Your best bet in these situations is to let common sense prevail. Did the same-session procedure require a separate approach, significant extension of the initial approach, and a separate closure? If so, you can probably treat the same-session procedure as additional and separately billable with modifier 59.