General Surgery Coding Alert

For instance, a surgeon implants a subcutaneous reservoir to administer long-term medication (36533, Insertion of implantable venous access device, with or without subcutaneous reservoir). A few hours later, the patient's condition worsens, and complications contraindicate using the subcutaneous reservoir. Therefore, the surgeon opts to place a central line (36491*, Placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperali-mentation, hemodialysis, or chemotherapy]; cutdown, over age 2) to provide immediate relief. Although CCI lists 36533 and 36491 as mutually exclusive procedures, in this circumstance medical necessity dictates using a central line following reservoir placement. You may report both codes, but to indicate the separate, unusual nature of the cutdown catheter (and to override the CCI code pair edit), you must append modifier -59 to 36491. Provide supporting documentation to justify the claim.

Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code, Jandroep says. Only CCI edits with a status indicator of "1" may be unbundled using modifier -59. You may not unbundle those code combinations with a status indicator of "0" under any circumstances. You need not append modifier -59 if CCI does not bundle the multiple procedure codes you are billing. For more information on CCI edits, see General Surgery Coding Alert, November 2002.

Surgeons will find many instances in which modifier -59 is appropriate. For example, a surgeon tends to a child with multiple leg wounds who has fallen from a playground swing. She performs intermediate repair and closure for several wounds on the child's right leg, totaling 12 cm, and tends to two simple repairs on the left leg, totaling 8 cm. You would report the intermediate repairs with 12034* (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm), and the simple repairs as 12004* (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).

Because the descriptor for wound care codes specifies only general anatomic location (e.g., trunk and/or extremities), payers cannot easily discern that the intermediate and simple repairs occurred at different sites. As a result, many payers will bundle the simple repair to the intermediate repair of the same anatomic location, says Cynthia Thompson, CPC, senior coding consultant with Gates, Moore & Company, an Atlanta-based medical management consulting firm. Appending modifier -59 to 12004 specifies that the simple repairs occurred at a different site and, therefore, are distinct procedures deserving separate reimbursement. In this example, the surgeon might also append modifier -RT (Right side) to 12034 and modifier -LT (Left side) to 12004 to further differentiate the procedures.

As a second example, the surgeon must repair a hernia at a separate site during gall bladder repair, e.g., 47740, Cholecystoenterostomy; Roux-en-Y. To indicate the separate anatomic site and override the CCI edit bundling associated hernia repairs to the gallbladder surgery, append modifier -59 to 49560 (Repair initial incisional or ventral hernia; reducible).

CPT instructs providers that modifier -59 is not a "catchall," and you should report it only if no other, more specific modifier applies, e.g., modifiers - 51 (Multiple procedures), -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period), says Sharon Tucker, CPC, president of Seminars Plus, a Fountain Valley, Calif., consulting firm specializing in coding, documentation and compliance.

For example, 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, followed by a modified radical mastectomy (19240, Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

Although CCI bundles 19120 to 19240, the surgeon's documentation indicates that the biopsy results led to the decision to perform the mastectomy, so the excisional biopsy is separately payable with the appropriate modifier. In this case, most Medicare carriers want you to append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) not modifier -59 to 19240. This indicates that the surgeon prospectively planned the second procedure (the mastectomy) at the time of the original procedure (the excision) and that it is "more extensive than the original."

Note: These guidelines apply primarily to Medicare payers. Some third-party payers may still require modifier -59 in the above circumstance. For more information, see General Surgery Coding Alert, January and April 2002.

Similarly, if the physician must perform two or more endoscopies for the same patient in the same day (e.g., to control bleeding), modifier -78 more appropriately and precisely describes the situation than modifier -59.

Modifier -59 should not be appended to E/M codes, Tucker warns. Rather, to be paid separately for an E/M service that CCI bundles into a global surgical package, you must provide appropriate documentation and append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Jandroep and Tucker agree that unlike some modifiers, including -51, modifier -59 should not lead to reduced reimbursement. Do not reduce your fees when billing, and appeal if the payer reduces your modifier -59 claims. In some cases, reimbursement with modifier -59 is carrier- or situation-driven. If this is the case, you may protest the reduction, but be sure to get the carrier's guidelines in writing and follow them.

When using modifier -59 in addition to surgical modifiers such as -51, -78 or -79, be sure to append modifier -59 last. Also, you should append modifier -51 in addition to modifier -59 if the -51 would otherwise be correct. If you use modifier -51 with -59, however, there should be a reduction in payment. Just because many carriers pay at full value doesn't mean it is correct, and there is no guarantee that payers won't come back later to recoup payments made at full value that should have been reduced as secondary procedures.

Because modifier -59 can unbundle CCI edits and increase payments, payers may specially scrutinize claims containing it. You should not use modifier -59 indiscriminately as a way to increase payments or "protest" CCI coding edits.

Although it isn't necessary to include full notes with every claim, as one would with modifier -22 (Unusual procedural services), the insurer may request additional documentation. Therefore, always keep thorough notes available to substantiate using modifier -59 (whether to collect a claim or in case of an audit). In addition, using different diagnoses when applicable for each CPT code reported will help to establish medical necessity.