If Used Correctly, Modifier 59 Can Boost your Healthcare Practice’s Revenue

by | Published on Jun 12, 2012 | Medical Billing

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Modifier 59 is a Level I CPT code used to report that a particular procedural service was carried out. It should typically be applied to the secondary code in a pair of codes and not added to Evaluation & Management Codes. If you use this code correctly for unbundling and are able to provide supporting documentation for its use, you can protect yourself from being penalized for incorrect use of the code and also increase your healthcare practice’s revenue. By unbundling codes suitably, you make them separately payable in accordance with Medicare guidelines.

Dishonest Use of the Medical Coding Modifier is Very Common

Modifier 59 is being abused a lot to unbundle codes that are not really separately payable. That’s why the OIG (Office of Inspector General) continues to monitor its unscrupulous use. In 2005, they brought out a 27 page report which highlighted an investigation they had carried out to learn to what extent modifier 59 was utilized to dodge Medicare’s National Correct Coding Initiative Edits. The paper reported the most commonly unscrupulously unbundled codes and issued suggestions to carriers such as the CMS to continue carrying out modifier 59 audits (pre and post-payment).

The Right Way to Use It

According to the 2012 CPT book, “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.” The documentation supporting its application should show that the two procedures were carried out under any of the conditions given below:

  • utilizing separate incision sites
  • on two different lesions
  • on two different organ systems
  • on two different injuries, or regions of injury in a situation of widespread injury
  • on varied anatomical sites
  • one of the procedures was utilized as a diagnostic instrument to establish that the second procedure should be consequently carried out

It is also mentioned in the CPT manual that modifier 59 should only be utilized when no other modifier would explain the service more suitably. Further, there are occasions when the modifier cannot be attached to bundled codes in spite of documentation in the record appearing to indicate it. This is so in the case of codes which are regarded as so essentially a part of each other that they are not independently payable. Such codes usually get edits incorporating the verbiage “may not be unbundled using any modifier.” In such a situation, modifier 59 cannot be utilized to override the edit.

The Biggest Mistake

The biggest mistake associated with the utilization of modifier 59 stems from this part of its definition – “different procedure or surgery.” Supposing a physician finishes annihilation of a premalignant or benign lesion, CPT code 17000, and also carries out a biopsy on a lesion on a different location, CPT code 11000, the use of modifier 59 is perfectly justifiable. If however, he has to carry out a laparotomy for investigation, CPT code 47015, and determines that the appendix has to be excised, CPT code 44955, appending of modifier 59 would not be the right thing to do. The reason is this: laparotomy would be seen as a vital element of the appendectomy and other procedures that are carried out through that particular incision at that particular location on that date.

An Established Service Provider Would Be Able to Help

To ensure that you do use modifier 59 correctly and to your advantage, you may want to get help from an established and reliable medical coding and billing service provider. You would also save considerably on operating costs by doing so.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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