Oncology & Hematology Coding Alert

Question: One of our private payers uses the National Correct Coding Initiative (NCCI) edits but does not recognize modifier -59, and this causes a lot of denials. What should we report instead?

Massachusetts Subscriber
 
Answer: Many private payers do not honor certain modifiers, and modifier -59 (Distinct procedural service) tops the list.
 
Because your insurer recognizes the NCCI edits, you should ask the payer how you should submit claims that would normally warrant modifier -59. You may need to ask such payers to include language in their participation contracts that advises how to process such claims. This way, you can protect your reimbursement rights and ensure reimbursement when you perform two medically necessary services that other payers allow you to report using modifier -59.
 
For example, you submit 96414-59 (Chemotherapy administration, intravenous; infusion technique, initiation of prolonged infusion [more than 8 hours], requiring the use of a portable or implantable pump; distinct procedural service) for the oncologist's chemotherapy services. The insurer may ask you to submit the claims on separate claim forms or append a different modifier instead.
 
Remember to use modifier -59 only when you can report no other appropriate modifier. This way, you won't confuse modifier -59 use with situations in which another modifier, such as -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or -76 (Repeat procedure by same physician), would be more appropriate.