Cardiology Coding Alert

Question: Different insurance companies tell me different things about where to place modifier 59. Should I append it to the primary procedure or the secondary?

Pennsylvania Subscriber

Answer: If you have instructions in writing from the payer, experts advise you to follow those instructions. In the absence of instructions to the contrary, you should append modifier 59 (Distinct procedural service) to the column 2 code.

Rationale: Medicare has at least two instructions regarding modifier 59 placement:

1. On CMS's Correct Coding Initiative (CCI) Web page (www.cms.hhs.gov/NationalCorrectCodInitEd/), there's a link to FAQs at the bottom. The FAQ with ID 3517 instructs providers to append modifier 59 to the column 2 code.

2. Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1.B, says to append modifier 59 to the "secondary, additional, or lesser procedure(s) or service(s)."

Some experts advise always appending modifier 59 to the column 2 code while others say to use it on the lower priced (lesser) procedure, which is often the column 2 code. But, again, if you have instructions in writing form your payer, let those guide your choice.

Example: The cardiologist's documentation states that she placed a stent in one vessel (37215, Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection) and performs thrombectomy in a different vessel (37184, Primary percutaneous transluminal mechanical thrombectomy,noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection[s]; initial vessel). CCI bundles 37184 (column 2) into 37215 (column 1). For a typical payer, you'll append modifier 59 to 37184. Medicare's national rate for this code is roughly $475, while 37215 pays roughly $1160.