Modifiers provide payers with the additional information that they need in order to process your claim. Suppose, for instance, that the physician excises a lesion of the right lower lid and biopsies a separate lesion on the same lid. Two separate procedures were performed, but if you fail to flag that fact (which is done by appending modifier –59 to the procedure code), your insurance company will assume that the physician biopsied and then excised the same lesion.
The OIG’s Concerns
Modifier –59 also unbundles Correct Coding Initiative comprehensive edits. In 2001, Medicare paid $565 million to providers who included modifiers unbundling code pairs in the CCI. Part of the OIG work plan in 2004 is to determine whether claims were paid appropriately when modifiers were used to bypass CCI edits.
Unbundle CCI Edits Correctly
In the CCI, each code pair is assigned a modifier indicator of 0, 1 or 9:
- The 0 indicator shows that there are no circumstances in which a modifier is appropriate to unbundle the edits as they are mutually exclusive.
- The 1 indicator means that a modifier is allowed in order to differentiate between the services provided at the same session on the same site.
For those procedures that have a 90-day global period, modifier –59 is appropriate.
For those services that have an xxx indicator for a global period or those procedures that have a zero- or 10-day global period, it is appropriate to append modifier –25.
- The 9 indicator is used for all pairs that have been deleted where the deletion date is the same as the effective date.
In each of the following examples, the need for performing the dual procedures must be well documented preoperatively and scheduled with the ambulatory surgery center or hospital, and both procedures should be independently dictated in the operative report.
Example 1. How do you bill for vitrectomy, pars plana lensectomy and IOL insertion, right eye?
Use these codes:
CPT code 67036–RT and
CPT code 66984–59–51–RT.
Example 2. How do you bill for retrieval of dropped posterior chamber lens and exchange of IOL, left eye?
Use these codes:
Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier –59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.
This may represent:
- different session or patient encounter,
- different procedure or surgery,
- different site or organ system,
- separate incision/excision,
- separate lesion, or
- separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.
However, when another already established modifier is appropriate it should be used rather than modifier –59.
Only if no more descriptive modifier is available, and the use of modifier –59 best explains the circumstances, should modifier –59 be used.