Neurology & Pain Management Coding Alert

Be sure to check CCI for a -1- modifier indicator Properly applying modifier 59 is essential for reimbursement when medical necessity and the documentation support its use (such as nerve conduction studies to multiple sites), but you should never report modifier 59 carelessly or merely to get claims paid. Payers know that this modifier is ripe for abuse, and time and again modifier 59 use comes under increased scrutiny from Medicare, the HHS Office of Inspector General (OIG) and other payers. Here are four expert-approved ways to bulletproof your modifier 59 claims. 1. Here's How to Recognize When 59 Applies You may use modifier 59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure the neurologist provides on the same date. Specifically, CPT -- backed by guidelines found in Chapter 1 of the National Correct Coding Initiative (CCI) -- instructs that you may append modifier 59 to your claim when a physician: - sees a patient during a different session - treats a different site or organ system - makes a separate incision/excision - tends to a different lesion - treats a separate injury. Example: Your neurologist completes an EEG and sleep study on the same patient the same date. Payers may object because EEG recording is part of a sleep study -- but not if the physician completes the tests for different diagnoses. Append modifier 59 to the procedure code and include the multiple diagnoses the neurologist documents to support separate billing. CPT instructions indicate that you should not report modifier 59 if another, more specific modifier (such as modifier 58, Staged or related procedure or service by the same physician during the postoperative period) describes the situation better. In addition, you should never append modifier 59 to any E/M service code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization in Salt Lake City. 2. Look to CCI for Bundles, Options If you have any doubt that two procedures are subject to bundling edits, simply check the CCI. If the CCI lists any two codes as "mutually exclusive" or pairs them together as "column 1" and "column 2" codes, you know the procedures are bundled, and you would not normally report them together. Note: All procedures identified as "separate procedures" by CPT will be subject to extensive bundles by CCI, Cobuzzi says. When you may unbundle: Even when documentation supports a separate site, excision, patient encounter, etc., don't expect to automatically override a CCI edit using modifier 59. Before filing your claim, check the correct coding modifier indicator for the bundled code pair you wish to report. Here's how: [...]