Neurology & Pain Management Coding Alert

If documentation won't support a separate service, don't unbundle If you're using modifier -59 indiscriminately, 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, be sure the neurologist's documentation makes clear the distinct and separate nature of the procedure to which you are appending modifier -59 Don't Treat -59 as a Catchall 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," as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it.
 
Coding example 1: For pain relief, the neurologist administers two neurolytic injections to the patient, one each at cervical (62281, Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, cervical or thoracic) and lumbar (62282, ... epidural, lumbar, sacral [caudal]) spinal levels.
 
In this case, because the surgeon provides the injections at separate locations, he is entitled to seek payment for each injection.
 
You shouldn't apply modifier -59 in this case, however: The National Correct Coding Initiative doesn't bundle 62281 and 62282, and you can achieve separate payment simply by appending modifier -51 (Multiple procedures) to 62282. And even this may not be necessary for many payers. "Modifier -51 is falling out of favor with payers," Bucknam says. "In most cases, the payer's software automatically detects 'additional' procedures and reimburses for them accordingly."
 
Coding example 2: In a second case, the neurologist sees an established patient for a scheduled trigger point injection (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]). During the visit, however, the patient complains of new symptoms of muscle weakness (728.87). The neurologist administers the injection, but also conducts an E/M service (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient...) and EMG (95861, Needle electromyography; two extremities with or without related paraspinal areas) for the new complaint.
 
Because payers will generally bundle an E/M service into any injection or other service, you will have to use a modifier to be paid for the neurologist's evaluation of the new symptoms of muscle weakness.
 
Again, however, you should not turn to modifier -59. Rather, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M service code [...]