Oncology & Hematology Coding Alert

Hint: Look to other modifiers and NCCI edit pair modifier indicators for correct application.

You know how helpful the “unbundling modifier” — modifier 59 (Distinct procedural service) — can be when you need to unbundle procedures. “When the time is appropriate, the 59 modifier can be very useful,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. However, its overuse, and particularly its misuse, means “that payers are taking long looks whenever they see it,” Hauptman cautions.

To avoid that scrutiny, here are two scenarios to help you understand the right — and the wrong — ways to append modifier 59 whenever you have to demonstrate that your provider legitimately performed two similar, yet different, procedures.

Understand When 59 May Not Be the Best Modifier Choice

Scenario 1: A patient with metastatic breast cancer receives two 5 mL injections of Faslodex in her left and right buttocks at the same encounter.

In this situation, providing the injection or medication administration record supports they were each given at a separate time in a separate location, you will need to use a modifier to indicate that the provider administered two injections at different sites. One way to do that is to place 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic) on the first line of the claim, followed by 96402-59 on the second.

However, in this, and other, scenarios, “it is important to understand the payer. What do they want to see?” regarding modifier choice, according to Hauptman. Modifiers for specific anatomic sites, for example, may be more appropriate under the right circumstances. So, you should check with your payer to see if they want you to use modifier 59 or XS (Separate Structure, a service that is distinct because it was performed on a separate organ/structure) on the separate lines.

Remember: Modifiers for the right side (RT), left side (LT), left thumb (FA), left fingers (F1-F4), right thumb (F5), right fingers (F6-F9), left big toe (TA), left toes (T1-T4), right big toe (T5), and right toes (T6-T9) also exist and could be used as determined by your provider’s notes.

Additionally, while private payers have been slow to adopt them, you may have the option to use one of Medicare’s X{ESPU} modifiers. In this encounter, the most appropriate of these would be the XS modifier. Depending on encounter specifics, you could also use:

• XE (Separate Encounter, a service that is distinct because it occurred during a separate encounter), which you would use for multiple encounters on the same date;
• XP (Separate Practitioner, a service that is distinct because it was performed by a different practitioner), which you would use when different practitioners perform the same procedure; and
• XU (Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service), which you would use when your provider performs different services on the same structure or anatomical site that involve distinct components.

These modifiers “better define why you feel the need to modify the service you are submitting,” Hauptman notes. But in order to use them, you should always ask if “the documentation clearly supports the separate nature of the two services,” Hauptman cautions.

Understand When 59 Will Not Work

Scenario 2: Your provider administers stereotactic radiosurgery (SRS) to treat a patient’s small brain tumor. You code the procedure as 77371 (Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based) for the SRS and 20660 (Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) for the placement of the head frame.

As the two procedures are a bundled National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edit pair, you may think you can apply modifier 59 to the 20660 so your practice can be reimbursed for both services.

In this particular situation, however, you cannot unbundle these services. To understand why, you have to understand why CMS regards the services as bundled, and how they indicate this in the NCCI PTP edit table.

The Centers for Medicare and Medicaid Services (CMS) created the system of edit pairs to enable proper payment for services when performed together. Procedures that might logically be performed together are grouped into two columns, with the service described in the second code (the column 2 code) being regarded as a part of, or overlapping with, the service described in the main, or column 1, code.

The edit pairs are then assigned modifier indicators of 0 (not allowed), 1 (allowed), or 9 (not applicable). You can unbundle any edit pair assigned a modifier indicator of 1 with an NCCI-approved modifier as long as documentation supports doings so; for edit pairs with a 0 indicator “there are no modifiers associated with NCCI that are allowed to be used with this PTP code pair.” Consequently, “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider” per CMS guidelines (Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).

In our particular scenario, there is a modifier indicator of 0 when 20660 is the column 2, or component code, to 77371 because CMS regards placement of a stereotactic head frame (the service described by 20660) as an integral part of the service described by 77371. So, the column 2 code, the 20660, is not separately reimbursable, and you cannot append modifier 59 on the service to receive additional reimbursement.