Primary Care Coding Alert

Question: In the June 2003 Family Practice Coding Alert article on lacerations, you suggest using modifier -51 for multiple wounds on different sites. Would modifier -59 be appropriate? Or does that not apply in this case?

California Subscriber Answer: CPT specifies (Appendix A, Modifiers) that you should use modifier -59 (Distinct procedural service) for a separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician, among other circumstances. But modifier -59 is the modifier of last resort. When another already established modifier is appropriate, it should be used rather than modifier -59, CPT says. Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used.

When choosing between modifier -59 and -51 (Multiple procedures) for claims containing multiple laceration codes, first determine if the National Correct Coding Initiative (NCCI) bundles the codes. You should use modifier -51 if no bundles exist. When more than one classification of wounds is repaired, CPT directs you to use modifier -51. If the NCCI bundles the claimed codes, you should instead use modifier -59 to override the edit. Otherwise, the payer, if it follows the edits, will reject the component code as bundled into the more comprehensive code.

In the article Are You Sewing Up Scrapes Correctly? A 4-Step Test Will Ensure Flawless Coding, a child falls off his bike and requires a 2.8-cm simple repair on his left shoulder (12002*, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm), a 1.1-cm superficial repair on his left ear (12011*, Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less), and a 3.9-cm layered closure on his knee (12032*, Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm). NCCI 9.2 does not consider these three codes bundled. Thus, modifier -59 is not necessary. According to CPT, you should instead use modifier -51 on the subsequent codes (12011-51; 12002-51) to indicate multiple repairs of more than one wound classification: simple, intermediate and complex.

In contrast, if the example in the article used bundled codes, modifier -59 would apply. Suppose the boy instead has a 2.8-cm superficial wound on his left shoulder (12002) and a 2.6-cm simple laceration on his right cheek (12013* 2.6 cm to 5.0 cm). In this case, because NCCI bundles 12013 into 12002, you should append modifier -59 to the component code (12013-59) to indicate a separate injury. Thus, both lacerations are separately reportable.