ÐÇ¿ÕÈë¿Ú

Look for a Separate Location or Session Before You Append 59

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 a recent 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 ÐÇ¿ÕÈë¿Únational 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 [...]

- Published on 2007-12-20