Pulmonology Coding Alert

Using modifier -59 (Distinct procedural service) can optimize a pulmonologist's bottom line, but improper use or abuse can lead to denied claims, audits or allegations of fraud. Modifier -59 is important because it enables pulmonary physicians to receive separate reimbursement for procedures that are usually bundled if provided on the same date of service, but that in a particular instance are distinct or independent of one another.

"Modifier -59 was created in response to Medicare's Correct Coding Initiative [CCI]," says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C. She explains that Medicare accepts this modifier when the physician uses it to show that services that are normally bundled by CCI are not integral to the comprehensive service the physician performed, but distinct and separately reportable. When Is -59 Appropriate? According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." Such circumstances may include the following:
a different session or patient encounter a different procedure a different site or organ system (perhaps the most common use of the modifier) a separate incision/excision, lesion or injury or area of extensive injury not ordinarily encountered or performed on the same day by the same physician. Specifically, physicians use modifier -59 to unbundle CCI code-pair edits. For example, a pulmonologist performs a bronchoscopy with transbronchial lung biopsy with fluoroscopic guidance for the right lung and then a bronchoscopy with biopsy on the left lung. Because the physician took the biopsies at different sites, you should report 31628-RT (Bronchoscopy [rigid or flexible]; with transbronchial lung biopsy, with or without fluoroscopic guidance; right side) and 31625-59-LT (... with biopsy; left side), says Toni Revel, CPC, a coding expert and nurse practitioner based in Warrington, Pa.

"Commercial payers may base their bundles on CPT guidelines and definitions, separate procedure designations, or the internal policies of the individual payer," Richardson says. "Because CCI is CMS' program, you should be aware of whether or not your payers follow Medicare's bundling guidelines or if they have their own bundling guidelines." Modifier -59 Is Not a Magic Wand CPT instructs coders that modifier -59 is not a "catchall" and should be reported only if no other more specific modifier applies, e.g., modifiers -51 (Multiple procedures), -78 (Return to the operating room for a related procedure during the postoperative period) or -79 (Unrelated procedure or service by the same physician during the postoperative period). For example, a pulmonologist sees a patient having an acute asthma attack. The physician has to administer two inhalation treatments in one day, due to the severity of the patient's condition. Modifier -59 [...]