Part B Insider (Multispecialty) Coding Alert

Published on Wed Jan 16, 2008 PDF

This practice fought its carrier--and won

You don't have to eat the cost of modifier 59 denials if you-re sure you-ve applied it correctly.

The problem: One Part B carrier began denying a practice's claims when the physician would biopsy a skin lesion and destroy a common wart, both on the same site.

The solution: This practice fought back and won after hiring an independent arbitrator to investigate the insurer's decision.

Today we-ve got three steps that can help you overturn your modifier 59 (Distinct procedural service) denials when warranted.

Step 1: Know when you-ve used modifier 59 properly. -Our physician frequently performed multiple skin procedures during the same session,- says Dawn FitzSimmons of Rocklin Internal Medicine. -At first we accepted the denials, but eventually the amounts started to add up, and we decided to appeal.-

FitzSimmons first investigated whether she used the modifier properly. -According to CPT's modifier 59 description, we knew we met the requirements for using it,- she
says.

Specifically, CPT--backed by guidelines found in Chapter 1 of the national Correct Coding Initiative (CCI)--instructs that you may append modifier 59 to your claim when a physician sees a patient during a different session, treats a different site or organ system, makes a separate incision/excision, tends to a different lesion, or treats a separate injury.

Step 2: Always attach 59 to the -secondary- code. When you append modifier 59, you should always append the modifier to the -lesser- or -separate procedure- code (typically the code in column 2), says Heather Corcoran, coding manager at CGH Billing.

Therefore, in the example above, you should append modifier 59 to the component code, 11100 (Biopsy). Link the procedures to the appropriate ICD-9 codes, such as 17000 (Destruction) to 702.0 (Actinic keratosis) and 11100-59 to the pathology report's biopsy diagnosis.

Step 3: Take your appeal to the next level when necessary. If your insurer's medical director won't consider your appeal, contact an independent arbitrator. -Our medical director had no familiarity with lesions, so we knew we needed a third party to step in,- FitzSimmons says.