Radiology Coding Alert

Modifiers -51 and -59 have similar applications to tell the insurer that you performed separate, medically necessary services during the same treatment session but many coders  (and carriers) have trouble selecting the appropriate modifier for certain services. The following modifier tips will help you determine when to use each of these commonly misapplied modifiers.

Unbundling NCCI Edits? Try -59

According to CPT Codes, you should apply modifier -59 (Distinct procedural service) if your services fit into any of five situations: different sessions or encounters, different sites or organ systems, separate incisions/excisions, separate lesions, or separate injuries (or areas of injury).

These situations seem to describe a wide range of scenarios, and radiology practices often take these examples to mean that they should always append modifier -59 when they want to separate services. But many coders refer to -59 as the modifier of last resort. Because of this difference of opinion, some radiology practices arent sure when they can and cannot report modifier -59.

Its confusing because modifier -59 is the modifier of last resort, but its also a National Correct Coding Initiative (NCCI) unbundler, says Jeff Fulkerson, BA, CPC, CMC, certified coder for the department of radiology at The Emory Clinic in Atlanta. If youre trying to separate services that NCCI normally bundles together, you should use a modifier to separate them, but it wont always be -59, he says.
 
Determine Whether Other Modifiers Fit

Before assigning modifier -59, you should first consider other modifiers, such as -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).

If, after considering the other options, -59 is still the most appropriate modifier, you should report it, Fulkerson says. He offers the following example: You perform a two-view chest x-ray at 9 a.m., but the patients condition worsens and her physician orders a one-view chest x-ray at 2 p.m. the same day.

In this case, modifiers -78 or -79 arent applicable, Fulkerson says. You should therefore report 71020 (Radiologic examination, chest, two views, frontal and lateral) for the morning x-ray, and 71010-59 (Radiologic examination, chest; single view, frontal) for the afternoon chest x-ray.

Remember that modifier -59 is only applicable if the NCCI edit carries a 1 modifier, says Tammy Boyer, CPC, coding and compliance administrator at Orthopedics and Sports Medicine in Burlington, Iowa.

Also remember that some services are truly supposed to be bundled together. And if a payer discovers that you append modifier -59 to separate all of the codes that the NCCI bundles (even when both are not separate and distinct), you could be a prime candidate for an audit.

Double-Check Your Documentation
 
If you plan to append modifier -59 to separate codes that the NCCI bundles, make sure your documentation is pristine, Fulkerson advises. You have to be able to demonstrate that the first service is separate and distinct from the subsequent procedures, and your documentation must reflect that, he says. If the physician hasnt documented the distinct nature of the two services, you cant report both codes. The physicians verbal statement isnt enough it has to be in the report.

Multiple Surgical Procedures? Try -51

When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the -51 modifier to the additional procedure or service codes(s), CPT states.

You should append modifier -51 (Multiple procedures) if you perform multiple procedures and you want to tell the insurer that you didnt list them on the claim in error. If, for example, you perform multiple CT or radiographic services (and particularly if you performed the same service more than once), you should append modifier -51 to the secondary procedure so the carrier wont automatically reject the second procedure as a duplicate.

Since Jan. 1, 1995, Medicare carriers have fixed payment for the second through fifth procedures at 50 percent of the total allowable relative value units (RVUs), while they pay the primary procedure in full.

Many carriers automatically append modifier -51 to what their computer systems identify as the secondary or subsequent procedures, so check your payers guidelines to determine whether they prefer to append modifier -51 or if you should.
 
Make Sure You Didnt Overmodify

To ensure that Medicare carriers pay their claims, some radiology practices append both modifiers -59 and   -51 to the same code on the same claim. The October 1999 CPT Assistant advises against this practice, stating, Since modifier -59 is to be used only if no more descriptive modifier is available, and the use of the -59 modifier best explains the circumstances, it would not be appropriate to append the -51 and -59 modifier to the same code on the same claim.

Although many carriers follow CPT and CMS guidelines, some insurers maintain individual policies regarding when you should apply modifiers -51 and -59 for given procedures. Always consult your carriers policies to determine whether local payer guidelines prevail over national policies.