Orthopedic Coding Alert

The OIG plans to crack down on -59 usage in 2005, so be careful If you think of modifier -59 as an easy way to collect when you bill bundled procedures together, you may gain extra reimbursement for your claims, but you could be asking for trouble. To avoid running afoul of CMS regulators, always be sure the surgeon's operative notes make clear the distinct and separate nature of the procedure to which you are attaching modifier -59 (Distinct procedural service).
 
Although several modifiers allow practices to unbundle National Correct Coding Initiative (NCCI) edits, orthopedic practices most often choose modifier -59 in order to separate code pairs. But in its recently released 2005 Work Plan, the Office of Inspector General (OIG) at the Department of Health and Human Services stated that it intends to scrutinize claims that include modifiers used to bypass NCCI edits. Therefore, it's more important than ever before to ensure that you're using modifier -59 appropriately. Follow our experts' advice to determine when you should - and should not - append modifier -59 to your claims. If Other Modifiers Will Do the Job, Avoid -59 You should never use 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.
 
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.
 
Note: See our Modifier -59 decision tool on page 93 to help you determine when you should select modifier -59 rather than other modifiers.
 
Coding example: The orthopedic surgeon attempts a percutaneous fracture fixation (26727, Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each) on a patient's left third finger but cannot complete the procedure. He converts to an open procedure and performs an open finger shaft fracture treatment (26735, Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without internal or external fixation, each).
 
What NOT to do: The NCCI bundles 26727 into 26735, but the edit contains a "1" modifier, which means you can separate the code pair if the physician documents two separate and distinct procedures, and you append a modifier. But in this case, because the physician converted a percutaneous procedure to an open one on the same finger, you are not justified in reporting both codes and appending modifier -59. Finger Modifiers Trump -59, When Accepted Caveat: If, however, the physician performs an open procedure on the [...]