Pathology/Lab Coding Alert

Correctly using modifier -59 (distinct procedural service) can help prevent denials for multiple procedures performed on a single patient on the same day.

Pathologists often carry out such multiple procedures, and each procedure should be coded individually. In fact, the CPT manual states, It is appropriate to designate multiple procedures that are rendered on the same date by separate entries. Unfortunately, doing so may appear to contradict the Health Care Finance Administrations (HCFA) Correct Coding Initiative (CCI) rules, leading to a denial of one or both of the claims.

Correct Modifier Usage Key

The correct use of modifiers is the solution to this problem, says Dari Bonner, CPC, CPC-H, CCS-P, compliance specialist and president of Xact Coding and Reimbursement, Inc., in Port St. Lucie, Fla. Specifically, modifier -59 would be used to indicate that a service is distinct and independent from any other service performed on the same patient, on the same day, by the same pathologist, she continues.

According to CPT, the circumstances that may warrant the use of modifier -59 involve procedures that are not normally reported together, but represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. CPT also notes that -59 should only be used if no more descriptive modifier is available.

Accurate use of modifier -59 requires a knowledge of which codes normally cannot be listed together based on Correct Coding Edits published in the National Correct Coding Policy Manual for Part B Medicare Carriers. These edits list code pairs that are excluded based on two relationships:

1. one code is comprehensive and includes the
service of the other, component code; or
2. the two codes are mutually exclusive, such as two different lab tests that measure the same factor.

Within the list of code pairs in the Correct Coding Edits, you will notice the use of superscript numbers 0 or 1 on some codes, says Bonner. A 0 means that a modifier would not be appropriate for that code pair under any circumstances. A 1 means that a modifier is allowed, if appropriate, she continues. In fact, Medicare requires the use of a modifier for any of these code pairs on which it is allowed if the same physician reports them together for the same patient, on the same day.

Comprehensive and Component Codes

Although coders must check the current version of Correct Coding Edits to get a complete list of excluded code pairs, many of the comprehensive and component codes are apparent in the CPT manual. For example, all the organ or disease oriented panels (80408-80090) are comprised of individual tests that also can be employed apart from the panel. The CPT code for each individual test is listed under the panel code. The CCI edits restrict the reporting of the panel code and its component test codes because that would represent unbundling a claim to bill for additional services. But if for some reason one of the component tests was done again on the same day as a distinct service, it would be appropriate to code for that component test with modifier -59.

The CPT manual also uses a convention of indentations and semicolons that indicates many comprehensive and component code exclusions in CCI edits. For example, code 88329 (pathology consultation during surgery) is followed by code 88331, which is indented and reads: with frozen section(s), single specimen. The CPT manual states that the indented code refers back to a common portion of the procedure (that part before the semicolon) listed in a preceding entry. Listing both 88329 and 88331 for a single consultation with frozen section would be inappropriate and would result in denial of the claim and possible charges of fraud.

Because these two codes are subject to a CCI edit, does that mean they can never be reported on the same claim? If a pathologist is called to surgery for a consultation involving a frozen section to establish a diagnosis of neoplasm of the colon, the appropriate code would be 88331 (pathology consultation during surgery, with frozen section). If the pathologist were later called back into surgery to consult on margins of the colon resection, the service would be coded 88329. This is when modifier -59 should be used. The second and any subsequent consultations for the same patient on the same day can be modified with -59 to avoid any confusion. Without the modifier, you would appear to be unbundling: the carrier would not know that the services represent two separate sessions, says Bonner. Ultimately, pathologists should consult with their particular carrier regarding reimbursement for these codes.

Some of the excluded comprehensive and component code pairs are not evident in the CPT manual, so you have to be familiar with the CCI edits, Bonner continues. For example, if a patient presents with unexplained anemia, the physician may order a bone marrow aspiration (85095) to be analyzed by the pathologist for cell maturation. Later, the physician may order a bone marrow biopsy (85102) to be analyzed by the pathologist for quantity and replacement of bone marrow. But because there is a CCI edit excluding the two codes from being used together for the same patient on the same day, modifier -59 would have to be used to ensure proper reimbursement.

Ruth Amicosante, office manager and 20-year billing and coding veteran at Englewood Pathologists, a hospital-based surgical pathology practice in Englewood, N.J., says, Were just starting to use modifier -59 for our Medicare billing to be in compliance with the CCI edits. She continues, Fine-needle aspiration [FNA] represents a procedure that we commonly report using modifier -59. If a patient has FNA of a deep breast lesion under radiologic guidance (88171), and later has a superficial lymph node aspirated (88170) on the same day, modifier -59 would be used. We would append the modifier to the second procedure that was done that day, Amicosante concludes.

Mutually Exclusive Codes

Modifier -59 is allowed less often in the case of mutually exclusive codes because these are often codes that, by CPT definition, would not occur together. For example, two screening Pap smears based on different methods would not be conducted on the same patient on the same day. That is why code 88164 (cytopathology, slides, cervical or vaginal ) and 88142 (cytopathology, cervical or vaginal, automated thin layer preparation ) are mutually exclusive codes. In cases like this, the modifier -59 is not allowed, as indicated by the superscript 0 by the column-two code in the Correct Coding Edits.

There are circumstances that allow the mutually exclusive code edits to be reported together, instructs Bonner. For example, a pleural fluid tap (88104) might be carried out for a patient with pleural effusion. That same day, the pathologist might interpret an aspiration of a mass in the lung for the same patient (88173). Although these codes are mutually exclusive in the CCI edits, they could be reported together in this case with the use of the modifier -59.

Which Code Receives the Modifier?

Modifier -59 is appended to only one of the two codes, but the question is, which one? Instructions from HCFA state, The secondary, additional, or lesser procedure(s) or service(s) must be identified by adding the modifier. Other direction comes from the list of CCI edits. Modifier -59 can be added only to the code on which it is allowed, which is indicated by the superscript 1. For pathology, these codes are generally in the second column of the two- column code pairs in the Correct Coding Edits.

Because pathologists often encounter multiple procedures for the same patient on the same day, familiarity with appropriate use of modifier -59 is crucial to ensure proper reimbursement. Even if the carrier does not require -59, like Medicare does, using it helps avoid confusion and the appearance of unbundling, says Bonner