General Surgery Coding Alert

Don't unbundle without rock-solid documentation

If you're indiscriminately using modifier -59, you may get your claims paid - but you could be asking for trouble with potential audits and big penalties.
 
To avoid running afoul of CMS regulators, always be sure the surgeon's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59

Don't Treat -59 as a Catch-All

You should never use modifier -59 (Distinct procedural service) if another modifier (or no modifier at all) will tell the story more accurately.
 
CPT guidelines clearly indicate "that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant. In other words, -59 is the modifier of last resort.
 
Coding example: For treatment of a Medicare patient, the surgeon performs an excisional breast biopsy (19120, Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion [except 19140], open, male or female, one or more lesions), which returns positive. Several days later he performs a modified radical mastectomy (19240, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

What NOT to do: The National Correct Coding Initiative (NCCI) bundles 19120 to 19240, but in this case you are justified in seeking additional compensation because the surgeon's documentation indicates that the biopsy results led to the decision to perform the mastectomy (and therefore the excisional biopsy is separately payable.).
 
You should not turn to modifier -59 in this situation, however (even though it might get you paid).

What to do instead: In this case, a different modifier, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), better describes the circumstances. Therefore, you should report 19120, 19240-58. The payer should recognize the separate nature of the mastectomy (as described by modifier -58) and reimburse accordingly.

Don't Unbundle Without Cause

Only append modifier -59 to a claim if you are certain of the distinct nature of the procedures you are reporting, and never simply to override NCCI bundles and get paid.

"[Modifier -59] is overused just to get through the edits," notes consultant Annette Grady CPC, CPC-H, with Eide Bailly in Bismarck, ND. Indeed, coders often turn to modifier -59 because "it unbundles nicely," says Laureen Jandroep, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

But, Jandroep cautions coders to remember that appending any modifier means you're saying you have the documentation to back it up.

For example: A patient reports to the ED after falling down stairs and cutting his right hand in several places on a broken windowpane. The surgeon closes a 1.5-centimeter laceration on the left second finger, as well as a 6-centimeter multi-layered laceration of the right palm.
 
Justified unbundling: NCCI bundles less extensive wound repairs to more extensive repairs at the same location. In this case, however, because the wound repairs occur in separate locations, you may report the procedures separately.
 
Claim 12042 (Layer closer of wounds of neck, hands, feet, and/or external genitalia; 2.6 cm to 7.5 cm) for repair of the right palm laceration followed by 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.5 cm or less) for repair of the left second finger. Be sure to append modifier -59 to 12001 to indicate that this repair occurred at a separate location.

Unjustified unbundling: In a second, similar case, the patient falls and receives three lacerations on his right forearm, including two wounds totaling 5 cm requiring layered closure and a single wound of 2 cm requiring simple repair. In this case, because the simple closure occurs at the same anatomical location as the layered closures, you may not report the simple closure separately.

Remember: Payers Are Watching

CMS is currently looking closely at -59, Grady believes. While each carrier and payer has different claims review software, you may safely assume that many carriers will single out claims with the -59 modifier for extra scrutiny.

The North Dakota Medicaid program actually handles all claims with the -59 modifier by hand, Grady adds. "It automatically pops them out," and reviewers go over the claims for medical necessity.

NOTE:  VIEW AN ADDITION TO THIS STORY IN OUR CORRECTION IN THE APRIL ISSUE.