Part B Insider (Multispecialty) Coding Alert

Published on Thu May 22, 2003 PDF

If you're slapping modifier -59 on your claims like there's no tomorrow, doomsday could in fact be upon you soon.

"It is a very dangerous modifier because a lot of times people think of it as a license to unbundle," says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J. That's because appending -59 (Distinct procedural service) to a code will essentially overwrite a National Correct Coding Initiative edit indicating it should be bundled with something else. And although using this modifier will usually get you paid, it doesn't mean you should be paid. And the feds often come after what they see as inappropriate reimbursement with a vengeance.

"If you disagree with a bundle that is part of CCI Edits , using -59 because you're mad about the bundle isn't appropriate," Cobuzzi warns. "Yes, you can get paid, but can you keep it and defend it - and defend that you weren't committing fraud?" To test whether you're using modifier -59 appropriately, ask yourself the following questions, Cobuzzi says:

1. Is it a separate site?

2. Is it a separate session?

3. Could I defend my use of modifier -59 in a court of law?

If the answer to each of these questions is "yes," you're in good shape. If not, think long and hard before putting modifier -59 on your claim.

That doesn't mean, however, that if the indicator is "1" you should necessarily use the modifier, says Cindy Parman, co-owner of Coding Strategies Inc., an Atlanta-based firm. "When a code combination lists indicator '1,' it means that if the documentation supports a separately identifiable service ... then it is appropriate to apply modifier -59." But if the physician performed both services in the same session or if one service "was integral to the other," you absolutely shouldn't use -59, she says.

Think of modifier -59 as the "Modifier of Last Resort," Parman says.

If you believe you've used modifier -59 appropriately but your carrier refuses to unbundle the claim, don't be afraid to ask for a review, says consultant Robyn Lee with Lee-Brooks Consulting in Chicago. Just be prepared to show documentation.