Practice Management Alert

Unbundle and get the $$$ you deserve by knowing when and how to use modifier -59

Appending modifier -59 (Distinct procedural service) to a code will essentially override a National Correct Coding Initiative (NCCI) edit indicating that the service should be bundled with another procedure performed during the same encounter. Although using this modifier will usually get you paid, it doesn't mean you should be paid. And the feds often crack down on what they see as inappropriate reimbursement. Brush up on proper modifier -59 use with these simple guidelines:

1. Remember, modifier -59 is not a license to unbundle. You cannot use -59 to override edits you think are improper or to unbundle mutually exclusive codes listed in the NCCI.

2. Confirm there is truly something separate about the two services the physician performed: a separate session or patient encounter, a separate site or organ system, or a separate procedure or injury.

3. Be sure the physician's documentation supports using modifier -59.

4. Verify that the NCCI allows you to use -59. If the NCCI lists the modifier indicator as "0" on the code pair you're planning to report together, you cannot use -59 to bypass the bundling edit. A modifier indicator of "1" means -59 is allowed to unbundle the codes.

5. Check for a more appropriate modifier to use. CPT instructs you to use modifier -59 only "if no more descriptive modifier is available." Quickly run through the list of other modifiers to see if another is more appropriate, such as -76/-77 (Repeat procedures), -58 (Staged or related service), -78 (Return to the operating room) or -79 (Unrelated procedure).

6. Be confident you could defend your use of -59 in a court of law. In the event of an audit or billing fraud investigation, you'll want to be sure your billing was compliant.