Ophthalmology and Optometry Coding Alert

Question: Medicare regulations indicate that separate ICD-10 codes are not required to report modifier 59, but we never seem to be able to get paid with this modifier unless we have separate diagnosis codes. What’s the story with this?

Codify Subscriber

Answer: Insurers essentially state across-the-board that separate ICD-10 codes are not required to use modifier 59 (Distinct procedural service). For example, CMS’ modifier 59 Fact Sheet says, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure.”

Private insurers typically maintain policies that list similar statements. If your payer specifically tells you that it won’t pay for a modifier 59 claim unless you use separate diagnoses, ask to see that policy in writing. If the payer is unable to produce the policy in writing, then you should appeal the denials as long as your documentation supports the medical necessity and separate nature of the two services.