Otolaryngology Coding Alert

To use modifier -59 (Distinct procedural service), make sure the incident meets three key components of the modifier's definition.

First, the modifier is intended to describe separate, distinct procedures or services that are performed on the same day by the same physician, says John Lavere, MBA, CPC, director of compliance for Charlotte Eye Ear Nose & Throat Associates in North Carolina. "Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day," states CPT 2002, Appendix A, page 382. Second, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances," according to CPT. You should not use the modifier to indicate another procedure that is often performed with the primary procedure, but make sure that both procedures are not normally reported together.

"Modifier -59 is not a universal unbundler," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryn-gology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "You should not consider the modifier a way to unbundle procedures or services."

Third, the definition provides examples of typical situations that the same physician may not ordinarily encounter or perform on the same day that warrant modifier -59. Those examples include: a different session or patient encounter a different procedure or surgery a different site or organ system a separate incision/excision a separate lesion a separate injury. "Look at modifier -59 as a tool," Cobuzzi recommends. When you receive denials that you disagree with, consider using modifier -59 if you can apply its definition to the particular situation at hand. "

Modifiers tell a story about why something should be paid more or paid less." They help carriers understand why two procedures that an insurer would not normally reimburse separately, should be paid that way.