Practice Management Alert

The OIG is focusing on modifier 59, and so should you.

With payers scrutinizing claims submissions for separate and distinct services, thanks to the OIG's reported error rates relating to modifier 59 use, you can't afford to make avoidable modifier 59 (Distinct procedural service) mistakes on your claims. Denials due to incorrect modifier 59 use cost your practice time and money, but perhaps even more critical is the red flag those claims wave at auditors.

Good news: You can avoid these claim errors and prevent possible paybacks by using these two tips.

Tip 1: Determine Separate Regions

Pull a sample of your modifier 59 submissions and verify that the claims properly represent a distinct procedural service. Fifteen percent of the OIG's audited claims using modifier 59 had procedures that weren't distinct because "they were performed at the same session, same anatomical site, and/or through the same incision," says Daniel R. Levinson, inspector general, in "Use of Modifier 59 to Bypass Medicare's Correct Coding Initiative Edits," an article posted on the OIG Web site www.oig.hhs.gov/oei/reports/oei-03-02-00771.pdf.

Rule of thumb: Make sure the physician is working in a separate body area before you use modifier 59.

Example: A pulmonologist performs a bronchoscopy and sees what appears to be lung cancer in the right upper lobe airways. He performs a bronchial biopsy of the lesion, and a brushing in the same area. However, to determine if the cancer has spread to the lymph nodes, he performs a transcharinal needle aspiration in the trachea.

You would report 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy[s], single or multiple sites) and 31623-51 (... with brushing or protected brushings), but also include 31629 (... with transbronchial needle aspiration biopsy[s], trachea, main stem and/or lobar bronchus[i]) on your claim. Code 31625 is considered a component of 31629. Append modifier 59 to 31625 to illustrate that the biopsy was taken from a site separate from the needle aspiration. This is an appropriate use for modifier 59.

Tip 2: Put 59 on the Secondary Code

Notice how the example above includes appending modifier 59 to the secondary code (31625). The Correct Coding Initiative publishes a list of comprehensive/component edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations, experts say. Each edit consists of a column 1 and column 2 code.

Review: If you report the two codes of a CCI edit for the same beneficiary for the same date of service without an appropriate modifier, the carrier will only pay for the column 1 code. The payer may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit. Although appending the modifier to the column 2 code may seem elementary, the OIG found numerous application errors.

Close call: Your modifier 59 payment was almost restricted to adhering to the "59 on the second code" guideline. The OIG encouraged carriers to pay claims only when modifier 59 is appended to the secondary code, not the primary, but CMS responded that it lacks the technical ability to put in place such an edit. Such an edit would have rejected payment for the following claim:  

Example: A urologist does a cystoscopic examination and transurethral resection of a large bladder tumor (52240, Cystourethroscopy, with fulguration [including cyrosurgery or laser surgery] and/or resection of LARGE bladder tumor[s]) located on the left lateral bladder wall and also performs a cystoscopic bladder biopsy (52204, Cystourethroscopy, with biopsy[s]) on the right side of the bladder.

You submit the coding:

• 52240-59
• 52204.

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (52240) instead of the component or column 2 code (52204).

Action: "If you notice that you have put modifier 59 on the wrong code, resubmit the claim," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. In the event of an audit, payers should look positively on your proactive stance, she adds.

Your corrected claim should look like this:

• 52240
• 52204-59. 

Bonus: You can test your modifier 59 skills with examples from the CMS modifier 59 article available online at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads//modifier59.pdf.