ED Coding and Reimbursement Alert

Read on for a recap of the rules with ED examples for using to avoid future audit trouble.

Reporting modifier 59 (Distinct Procedural Service) accurately in the ED requires that you understand the exact circumstances when it's appropriate to indicate your physician provided a service that was distinct or independent from other non-E/M services performed on the same day and which are not normally reported together. This can be hard to get right, but the adhering to five key rules can keep you in the winners' circle for your modifier 59 claims.

Context: Modifier 59 (Distinct Procedural Service), which has one of the longest descriptors in Appendix A of CPT®, is available for unique clinically appropriate situations that fall outside of the construct anticipated by many coding conventions, including the CCI edits, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company.  

The challenge: Chart documentation must support a different session, 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 individual, Granovsky instructs. 

Remember These Two Overarching Rules For Modifier 59

1. Modifier 59 is the "modifier of last resort," when another already established modifier is appropriate, it should be used rather than modifier 59.
2. Modifier 59 is for procedures only and should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, use modifier 25 (Significant separate E/M service by the same provider on the same day of the procedure or other service), Granovsky explains.

Granovsky offers 5 rules with ED examples to guide you to modifier 59 accuracy:  

1. Use modifier 59 different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

A common uses of modifier 59 is for surgical procedures or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI., says Granovsky.

NCCI edits are typically created to prevent the inappropriate billing of lesions and sites that should not be considered to be separate and distinct. You should only use 59 to identify clearly independent services that represent significant departures from the usual situations described by the NCCI edit. The treatment of structures in the same organ or anatomic region does not qualify as treatment of different anatomic sites. For example, treatment of the nail, nail bed, and adjacent soft tissue would not qualify. 

The 59 modifier may be used to indicate a separate anatomic location therefore it should not be used on procedures on contiguous or connected locations, warns Granovsky. 

ED example: A patient presents with a laceration of the proximal finger by the MCP joint and a noncontiguous nail bed injury on the same finger. As these are two distinct injuries and not connected, then the 59 modifier would be appropriate to indicate separate noncontiguous procedures. 

• 11760 (Repair of nail bed)
• 12001-59 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less)

2. Use modifier 59 when the procedures are performed in different encounters on the same day. 

Another common use of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers, says Granovsky.

The 59 modifier may be used to indicate procedures that occurred at different times on the same day. 

For example: An emergency room patient with asthma is evaluated with a chest x-ray in the morning during an initial ED visit. Later that evening, during a second ED visit the patient develops respiratory distress and is intubated. 

• 31500 (Intubation, endotracheal, emergency procedure)
• 71020-59 (Radiologic examination, chest, 2 views, frontal and lateral)

Keep in mind, if a more specific modifier is available, you should use it (example: a repeat EKG by the same physician would require a 76 modifier on the second procedure code), says Granovsky. 

3. Don't use modifier 59 if the only basis for its use is that the narrative description of the two codes is different. 

One of the common misuses of modifier 59 is related to the portion of its definition which indicates it may describe a "different procedure or surgery." 

The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be "separate and distinct." The provider should not use modifier 59 for such an edit based on the two codes being "different procedures", warns Granovsky 

However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures on that date of service, he explains.

ED example: A patient sustains a laceration of the fingertip which includes the skin and nail bed of the same finger that requires a repair. In this case, you would not use the -59 modifier to report both the laceration repair and the nail bed repair. You would not report both CPT® code 11760 (Repair of Nail bed) and code 12001-59 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less).

4. Use modifier 59 for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. 

When a diagnostic procedure precedes a procedure and is the basis for the decision to perform the surgical procedure, that diagnostic test may be considered to be a separate and distinct procedure as long as it meets these three tests:

(a) It occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention; 

(b) It clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and 

(c) It does not constitute a service that would have otherwise been required during the therapeutic intervention.  If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately. 

You can use the 59 modifier when a diagnostic procedure is performed prior to when a determination is made to perform a therapeutic procedure, says Granovsky. 

For example: An ED physician suspects laryngeal edema in a burn patient and performs flexible nasal fiberoptic laryngoscopy. Moderate edema is noted which subsequently worsens ultimately requiring intubation

• 31575 (Laryngoscopy, flexible fiberoptic; diagnostic)
• 31500-59 (Intubation, endotracheal, emergency procedure)

5. Use modifier 59 for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure. 

When a diagnostic procedure follows the surgical procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as it both:

(a) Occurs after the completion of the therapeutic procedure and is not otherwise associated with services that are only required for the therapeutic intervention, and
(b) Does not constitute a service that would have otherwise been required during the therapeutic intervention. 

If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately, advises Granovsky. 

Keep in mind: Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT® coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT® codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above, he adds. 

ED example: Consider these two codes to illustrate.

• 32551 (Tube thoracostomy, includes connection to drainage system (e.g., water seal), when performed, open [separate procedure]) 
• 71020-59 (Radiologic examination, chest, 2 views, frontal and lateral) 

Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. 

CPT® code 71020 should not be reported and modifier 59 should not be used for a chest x-ray that is performed following insertion of a chest tube in order to verify correct placement of the tube. Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure, Granovsky explains.

The 59 modifier is appropriate when a diagnostic procedure is not related to the procedure that precedes it. For example, a chest x-ray that is performed to confirm the placement of a central line should not be reported. However, if the chest x-ray is performed later the same day after the patient developed hypoxia, if would be appropriate to report with a 59 modifier.

• 36556 (Insertion of a non-tunneled centrally inserted central venous catheter; age 5 years or older) 
• 71010-59 (Radiologic examination, chest, single view, frontal).