MODIFIER 59BREAK 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

The Coding Institute, LLC . SuperCoder.com

Are rats smarter than humans?

Get Allowed Payment Faster

GoalsBust bundlesRecognize allowed boostersUse reducers when necessary

BenefitsIdentify services that are eligible for separate paymentAvoid dangerous unbundling habitsStop wasting time on unnecessary appeals

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

Modifier 59: The Bundle Breaker

CCI Origins

National Correct Coding Initiative (CCI)Created by Centers for Medicare and Medicaid Services (CMS)Purpose: To apply CPT coding conventions

Sometimes does,Sometimes doesn’t

CCI System

Column 1Comprehensive

Column 2ComponentIncludes

Critical care99291

Pulse Ox94760Includes

Exceptions

Some edits allow a modifier to override a bundled pairModifier 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.”Source: CPT 2009 Appendix A

Circumstance Criteria

Documentation must support a:different sessiondifferent procedure or surgerydifferent site or organ systemseparate incision/excisionseparate lesionseparate injury (or area of injury in extensive injuries)

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

No longer examples.

Alternative ‘Breaker’ Modifiers

United HealthCare (UHC) allows you to break a bundle with these modifiers:

58, 59, 78, 79, 91E1, E2, E3, E4LC, LD, LT, RC, RTTA, T1, T2, T3, T4, T5, T6, T7, T8, T9FA, 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

Source: CCI Editing Policy

Reserve 59 for 2 Procedures

shows service or procedure separate from E/M service1 service, 1 procedure

shows procedure or service distinct or independent “from other non-E/Mservice performed on the same day …”1 procedure, 1 procedure

Modifier 25 Modifier 59

Source: CPT 2009 Appendix A

CPT 2008 added

Modifier 59 Rules

1. Append to non-E/M codes only2. Not normally reported together,

but appropriate under circumstances

Different site or location3. No more descriptive modifier

applies

ECG, Unrelated Procedure

CCI 15.1 bundled ECG codes 93000-93010 into

Wart removal (17110)In/out catheterization (51701)Removal of impacted cerumen (69210)

Use 59 on component code when different reason

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

Is Inhaler Education & Training OK?

Col 1 RVUs Col 2 RVUs

94640 0.38 94664 0.39

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

Is Training at Separate Session?

Code only treatmentOccurs during treatment

Staff/physician shows steps while patient receiving treatment

9921x(25), 94640

Code treatment, training1. Patient receives treatment

Rescue medication2. MD decides education

necessary3. Staff does training

Maintenance medication

9921x(25), 94640, 94664-59

No, occurs during treatment Yes, occurs after treatment

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.

Tool

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.

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.

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.

Orthopedic Case Study 1

Your final codes should look like this:23412 for the open rotator cuff repair29826-59 for the arthroscopic acromioplasty29824-51 for the arthroscopic distal clavicle excision29823-59 for the arthroscopic extensive debridement.

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.

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.

For the fasciotomy, you should report 28008-51 (Fasciotomy, foot and/or toe).

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.

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 anything additional for twin B when the delivery is vaginal.

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.

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.

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.

Mary Compton, PhD, CPC

Look to Other Modifiers

Rule #3: If a more specific modifier describes the situation, you should not use modifier 59. 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 complianceUPMC departments of Surgery and Anesthesiology.

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?

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 associate with modifier 51 (Multiple procedures).

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)

Source: CIGNA’s Network News, July 2010

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

ICD-9-CM CD-ROM. Ninth Version. Centers for Disease Control & Prevention and the National Center for Health Statistics. Oct. 1, 2010

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

• United HealthCare, “CCI Editing Policy,” 2008R0105A, Dec. 9, 2009, http://www.littleurl.net/ec2e41

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Mary Compton, Editorial Director

Neurosurgery

Jen Godreau, Content Director, Supercoder.com

Family Practice, Pediatrics, Otolaryngology

Suzanne Leder, Executive Editor

Ob-Gyn , Orthopedics