Modifier Coding Alert

Reader Questions:

Use 59 When Physician Performs Procedure, Separate Therapy

Published on Thu Jun 18, 2015

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Question: An established patient reports to the office three days after injuring herself in a bicycle accident. The physician identifies an open, pus-filled wound on the patient’s left shoulder. Several centimeters from the deep shoulder injury, the patient has a less severe open wound, just below the collarbone. After debriding the patient’s shoulder injury, the physician removes scabs and dead tissue from the patient’s collarbone injury. Total treatment area for both injuries is 18 square centimeters. Here’s where it gets complicated: The patient was rehabbing a right knee injury at the time of the cycling accident. The physician performs a recheck evaluation to make sure the patient didn’t re-injure the knee. Is there a modifier I can use to ensure we get paid for both the injury check and the debridement?

Montana Subscriber

Answer: You will need to use modifier 59 (Distinct procedural service) to separately bill for the physical therapy re-evaluation and the debridement procedure.

Since the physician debrided wounds totaling 20 square centimeters or less, you should report 97597 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm], including topical application[s], wound assessment, use of a whirlpool, when performed and instruction[s] for ongoing care, per session, total wound[s] surface area; first 20 sq cm or less) for the debridement. For the knee recheck, report 97002 (Physical therapy re-evaluation). Append modifier 59 to 97002 to show that the debridement and knee recheck were separate services.

Rationale: Typically, the Correct Coding Initiative (CCI) bundles 97002 into 97597. If, however, the physician performs debridement (97597) on one injury and re-evaluation (97002) on a different injury during the same encounter, you can unbundle the codes using modifier 59.