Ob-Gyn Coding Alert

Reviewers automatically check -59 claims for necessity

Appending modifier -59 to this round of National Correct Coding Initiative (NCCI) ob-gyn procedure edits with a status indicator of "1" may be an easy fix to receive separate reimbursement - but you could attract unwanted regulatory attention.

Here's the scoop on how you can maximize modifier -59 (Distinct procedural service) use and your reimbursement, and minimize scrutiny.
 
Avoid Treating -59 as a Catchall

Don't fall into the trap of using modifier -59 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. You should be using modifier -59 only as a last resort.

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," says Annette Grady, CPC, CPC-H, a consultant with Eide Bailly in Bismark, N.D.

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.

Use Modifier -59 to Signify Distinct Procedures

You should use modifier -59 only when no other modifier applies to services performed by the same physician on the same day, and it is used to indicate that a procedure that would normally be bundled with other procedures was distinct during this surgical session. It is primarily used with codes that are designated as "separate procedure" in the CPT book, but it may be used in other circumstances as well.

Most often, it will be added to a code that is a separate procedure performed for a reason unrelated to the primary procedure. You may also use modifier -59 with the primary procedure if that procedure has the higher RVU. CPT states that this modifier is "appropriate under certain circumstances." They include:

1. A different session or patient encounter. This means the ob-gyn provides a distinct service during a different patient encounter - even though a similar procedure may be performed. For example, an ob-gyn performs a D&C (58120) in the morning, and the patient continues to bleed throughout the day. So the ob-gyn performs a hysteroscopy D&C that evening (58558). In this case, the hysteroscopy procedure has a higher RVU, so the code order is 58558, 58120.

"You may append the modifier to either procedure code because neither is listed in CPT as 'separate procedure,' " says Penny Schraufnagel, office manager for Ob-Gyn Center PA in Boise, Idaho.

2. A different procedure or surgery. For example, a patient has uterine fibroids, and the ob-gyn performs a TAH/BSO (58150). The patient also has a symptomatic enterocele that the ob-gyn repairs abdominally (57270-59).

3. A different anatomic site or organ system. The ob-gyn performs a vulvar lesion biopsy (56605) and, at the same session, he removes a 2.0-cm benign cystic lesion on the inside of her thigh (11402). Then you should report 11402, 56605-59.

 4. A separate incision/excision. An ob-gyn performs a laparoscopy with LSO (left salpingo-oophorectomy, 58661) and an aspiration of a cyst on the right side (49322). In this case, you should report 58661, 49322-59.

5. A separate lesion. A patient has an ovarian abscess and an ovarian cyst. The surgeon performs drainage of the ovarian abscess (58820) on the first ovary and then drains the ovarian cyst on the other ovary (58800-59).

6. A separate injury. Use modifier -59 if an injury occurs during a procedure and that injury necessitates another procedure. For example, during an abdominal procedure, the bladder is inadvertently torn and the ob-gyn must repair. The ob-gyn reports the primary procedure with 51860-59 (Cystorrhaphy). Note, however, that Medicare will not reimburse the ob-gyn for repairing an inadvertent injury.

Be Confident Beneath CMS' Spotlight

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

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

Tip: Each time you are unsure whether a carrier accepts modifier -59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification, says Linda Parks, MA, CPC, CMC, CCP, coding specialist in Marietta, Ga. Then, chart each carrier's policies on -59 so you know whether to use it the next time you file a claim.
 
Making these phone calls may take a little time initially, but once you get a chart with each insurance company's policy on modifier -59, your claims department will be streamlined dramatically.