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MODIFIER 59

BREAK BUNDLES WHEN YOU SHOULD

Jen Godreau, BA, CPC, CPEDC, Content Director Mary Compton, PhD, CPC, Editorial Director Suzanne Leder, BA, M.Phil, CPC, COBGC, Editorial Manager

(2)

Are rats smarter than humans?

(3)

Get Allowed Payment Faster

Goals

¾

Bust bundles

¾

Recognize allowed

boosters

¾

Use reducers when

necessary

Benefits

™

Identify services that

are eligible for

separate payment

™

Avoid dangerous

unbundling habits

™

Stop wasting time on

(4)

OIG 59 Findings

15% performed at same

session/site/incision

• Ex: chemotherapy, IV infusion •

25% lacked supporting

service(s) documentation

11% used 59 on primary

code, instead of

secondary code

13% had 59 on both

codes

(5)
(6)

CCI Origins

¾

National Correct Coding Initiative (CCI)

¾

Created by Centers for Medicare and Medicaid

Services (CMS)

¾

Purpose: To apply CPT coding conventions

Sometimes does, Sometimes doesn’t

(7)

CCI System

Column 1

Comprehensive

Column 2

Component

Includes Critical care 99291 Pulse Ox 94760 Includes

(8)

Exceptions

¾

Some edits allow a modifier to override a bundled

pair

¾

Modifier Indicators:

™

“0” — No modifier allowed

™

“1” — Modifier allowed

Unusual circumstance must warrant separate reimbursement

“… Modifier 59 is used to identify services/procedures, other than E/M services, that

are not normally reported together, but are appropriate

under the circumstances.”

(9)

Circumstance Criteria

Documentation

must support

a:

‰

different session

‰

different procedure or surgery

‰

different site or organ system

‰

separate incision/excision

‰

separate lesion

‰

separate injury (or area of injury in extensive injuries)

CPT 2008 revised from “may represent” to “must support”.

(10)

Alternative ‘Breaker’ Modifiers

United HealthCare (UHC) allows you to break a bundle

with these modifiers:

¾

58, 59, 78, 79, 91

¾

E1, E2, E3, E4

¾

LC, LD, LT, RC, RT

¾

TA, T1, T2, T3, T4, T5, T6, T7, T8, T9

¾

FA, F1, F2, F3, F4, F5, F6, F7, F8, F9

Nail avulsion (11730) on right ring finger and evacuation of blood under nail (11740) on right middle finger

Bundle breaker: 11730-F8, 11740-F7

(11)

Reserve 59 for 2 Procedures

¾

shows service or

procedure

separate from

E/M service

¾

1 service, 1

procedure

¾

shows procedure or

service distinct or

independent “from

other

non

-E/M

service performed

on the same day …”

¾

1 procedure, 1

procedure

Modifier 25

Modifier 59

Source: CPT 2009 Appendix A CPT 2008 added

(12)

Modifier 59 Rules

1.

Append to

non-E/M codes

only

2.

Not normally reported together

,

but

appropriate under

circumstances

†

Different site or location

3.

No more descriptive modifier

(13)

ECG, Unrelated Procedure

CCI 15.1 bundled ECG codes

93000-93010 into

¾

Wart removal (17110)

¾

In/out catheterization

(51701)

¾

Removal of impacted cerumen

(69210)

(14)

Test Yourself

…

A patient comes into have a wart removed (17110)

and at the visit complains of chest pain.

…

To evaluate the patient’s chest pain, the physician

takes a history, performs an exam, and as part of

medical decision making orders an in-office ECG to

evaluate the patient’s chest pain (ECG). The

physician documents his interpretation of the ECG

reading as revealing no heart-related problems.

Should you code the ECG?

Answer: A. Yes.

ECG is for a different reason than the wart removal so you can report the ECG.

• 9921x, 786.59 (Chest pain; other)

• 17110, 078.10 (Viral warts, unspecified) • 93000-59, 786.59

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Is Inhaler Education & Training OK?

Col 1

RVUs

Col 2

RVUs

94640

0.38

94664

0.39

Inhalation treatment Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device

(16)

Is Training at Separate Session?

¾

Code only treatment

¾

Occurs during treatment

™

Staff/physician shows

steps while patient

receiving treatment

¾

9921x(25),

94640

¾

Code treatment, training

1. Patient receives treatment

™ Rescue medication

2. MD decides education

necessary

3. Staff does training

™ Maintenance medication

¾

9921x(25), 94640,

94664-59

(17)

Combat Denials With Ammo

Typically, code 94640 does not include patient

education

. If separate medication instruction

occurs on the same day as an initial aerosol

treatment (

e.g.,

a different form of inhaler

requiring education

), code

94664 can be

used with a 59

modifier to indicate the distinct

procedural service.”

-- Steve G. Peters, MD, FCCP

“Continuous Bronchodilator Therapy,” Chest (2007; 131; 286-289) published by the American College of Chest Physicians Dept of IM, Div of Pulmonary & Critical Care Medicine at Mayo Clinic ~ Rochester, Minn.

(18)

Orthopedic Case Study 1

A 61-year-old male general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from

sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem.

The orthopedist’s physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear.

The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.

(19)

Orthopedic Case Study 1

A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear. You should begin with 29823

(Arthroscopy, shoulder, surgical; debridement, extensive), although you’ll need to append a modifier when you add other codes. You should then address the open rotator cuff repair, using 23412 (Repair of ruptured

musculotendinous cuff [e.g., rotator cuff] open; chronic).

How to decide between 23410 and 23412: If you choose 23410 (... acute)

instead of 23412, you will gain about $60 more reimbursement for this part of the surgery, but “acute” is not appropriate in this case. He’s been having this pain for over six months. “Acute” describes pain that began more recently, certainly within the past six months.

(20)

Orthopedic Case Study 1

Now look to the arthroscopy codes. The next codes on your claim should be 29824-51 (... distal claviculectomy including distal articular surface [Mumford procedure]; Multiple procedures) and 29826-59 (... decompression of

subacromial space with partial acromioplasty, with or without coracoacromial release; Distinct procedural service).

Why modifier 51 and 59? The Correct Coding Initiative (CCI) bundles

29826 into 23412, but you can override that edit in this case with modifier 59. CCI does not bundle 29824 with 23412, so you don’t need modifier 59 to override that edit. You simply need modifier 51 to indicate multiple

procedures. Keep in mind that some payers’ software, such as with Medicare’s, automatically applies modifier 51 for multiple procedure claims. Ask your payers whether you need to use this modifier.

(21)

Orthopedic Case Study 1

Your final codes should look like this:

…

23412 for the open rotator cuff repair

…

29826-59 for the arthroscopic acromioplasty

…

29824-51 for the arthroscopic distal clavicle excision

…

29823-59 for the arthroscopic extensive

(22)

Orthopedic Case Study 2

A 21-year-old male who was struck by an automobile while riding his bicycle presents to the ED with a serious crush injury to the left lower extremity with massive swelling, ecchymosis, loss of sensation in the foot, and tightness of all four lower leg compartments and of the foot. He also complains of left elbow and shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left calcaneal fracture, left radial head fracture, and clavicle fracture.

The orthopedist admits the patient. The patient undergoes immediate

surgery to stabilize his fracture and treat his acute compartment syndromes of the lower leg and foot. The surgery involves a closed reduction of the tibial plateau fracture with application of an external fixator. The

orthopedist plans open treatment of this fracture and the calcaneal fracture once the patient’s fasciotomy wounds are closed.

(23)

Orthopedic Case Study 2

The code with the highest relative unit will be the code for the closed treatment of the tibial fracture 27532-LT (Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction; Left side).

Next, report 20690-51-LT (Application of a uniplane (pins or wires in one plane), unilateral, external fixation system; Multiple procedures; Left side).

After that, you should report the decompression leg fasciotomy code. Depending on the compartments released, you would report 27600 for anterior and lateral,

27601 for posterior only, or 27602 for anterior and/or lateral and posterior. You’ll most likely report 27602, because the scenario describes all four compartments as tight. Depending on insurer, you might need modifier 51 on 27602. You can also apply modifier LT.

(24)

Orthopedic Case Study 2

Question: Should you rule out adding modifier 59 to

this claim?

Answer: Yes. Neither code has “separate procedure” designation, and the combination isn’t normally bundled. Adding modifier 59 to this claim is inappropriate because payers following CCI edits do not normally bundle these code

combinations, nor do the codes have “separate procedure” designations.

(25)

Ob-gyn Case Study 1

One of your ob-gyn’s regular patients is having twins, and your ob-gyn delivers them both vaginally. Two deliveries, however, do not mean you should submit two global ob codes.

Reality: You should report the global code (59400) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or

forceps]; Multiple procedures) for the second.

Heads up: You should know your payer’s preferences. Some insurance

companies instead prefer that you bill the additional delivery with modifier 59 (Distinct procedural service) attached. Other payers will not pay

(26)

Ob-gyn Case Study 2

You can report the tubal ligations following a vaginal delivery (59400, 59409, 59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 with modifier 59 (Distinct procedural service) appended.

Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery, even though they occurred during the

same session.

Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.

(27)

Ob-gyn Case Study 2

Watch out: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the ob-gyn has already done the prep work for the patient prior to delivery and therefore, payers don’t need to pay twice for the same work. In other words, they treat it just like any other multiple procedure.

If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). You should receive full reimbursement for the procedure.

(28)

Separate Session

Payers may be looking for evidence

that the separate procedure was done during a separate

encounter.

Ex. A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then

reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59?

Answer: You might think modifier 59 would be appropriate for the hernia code and that you could bill it

separately. But 59 tells the payer the hernia repair occurred during a

separate session, which isn’t true in this case. Modifier 22 (Increased procedural services) could apply here, provided you can support that extra work was done.

(29)

Look to Other Modifiers

¾

Rule #3: If a more specific modifier describes the

situation, you should not use modifier 59.

¾

Modifier 59 “should be the

modifier of last resort

and only used when there is no other modifier to

compliantly bypass the bundling edit and the

procedure was clearly

distinct and different

from

that of the other procedure.”

---Suzan Berman, CPC, CEMC, CEDC Senior manager of coding and compliance UPMC departments of Surgery and Anesthesiology.

(30)

Payment Reduction Quandary

Scenario:

The physician removes one lesion and biopsies another.

Medicare pays the removal at 100 percent and the biopsy at 50 percent. The carrier applies this payment reduction even though you use modifier 59 on the bundled procedure -- the biopsy.

Your dilemma:

Should you find an alternative way to code encounters like this so that you can avoid the fee reduction?

(31)

Payment Reduction Solution

… The answer: Normally, a lesion removal includes a biopsy. To indicate that the biopsy occurred at a separate site from the lesion removal -- and thus deserves separate payment -- you must append modifier 59 to the

otherwise bundled biopsy code.

… Don’t miss: Although same-session, separate-site lesion removals and

biopsies deserve separate payment, modifier 59 does not exempt the claim from multiple-procedure payment rule reductions, which you probably

(32)

… The list of code combinations requiring supporting documentation was reduced by approximately 25%, beginning May 17, 2010.

… Supporting documentation continues to be required on 79 code

combinations, approximately 1% of claims submitted with a modifier 59. This update represents a significant reduction in the number of edits

requiring documentation for dermatology services.

… The code pair list is available online with the Modifier 59 policy

Guideline Guidance

CIGNA : Modifier 59 Policy Supporting Documentation (UPDATE)

(33)

Resources

CIGNA’s Network News, July 2010, Modifier 59 policy (www.cignaforhcp.com > Resources > Clinical

Reimbursement Policies and Payment Policies >Modifiers and Reimbursement Policies)

• CPT 2010 Professional Edition, AMA, Jan. 1, 2010

ƒ ICD-9-CM CD-ROM. Ninth Version. Centers for Disease Control & Prevention and the National Center

for Health Statistics. Oct. 1, 2010

ƒ Medicare Physician Fee Schedule, CMS, Oct. 1, 2010

• National Correct Coding Initiative, version 16.3, CMS, Oct. 1, 2010,

https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

(34)

Save the Date!

What Happened at AMA

The scoop from the CPT® and RBRVS 2011 Annual Symposium

without the expense!

FREE Webinar

Tuesday, Nov 23

12:00 pm EST

Speaker: Jen Godreau, BA, CPC, CPEDC

• Observation coding changes

• You can recoup multiple vaccine components

Register at:

www.SuperCoder.com /conference

(35)
(36)

Ensuring reimbursement. Insuring coders.

Questions:

www.supercoder.com/forum/

Mary Compton, Editorial Director

Neurosurgery

Jen Godreau, Content Director, Supercoder.com

Family Practice, Pediatrics, Otolaryngology

Suzanne Leder, Executive Editor

References

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