Urology Coding Alert

Myth: Always use 59 to unbundle same-session, different-reason procedures

If you always apply modifier 59 and unbundle two procedures that the Correct Coding Initiative (CCI) bundles when a physician performs them during the same session but for different reasons, you had better rethink your modifier use.

You can apply modifier 59 (Distinct procedural service) only if your urologist performed the normally bundled procedures during different sessions, in different anatomical areas or if they were otherwise totally unrelated.

The bottom line: Missing the mark on modifier 59 is sure to get you in trouble with auditors. Prepare for Greater Scrutiny Many providers and coders believe they can use modifier 59 as long as they have different diagnoses or reasons for the procedures, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization based in Salt Lake City. This is a no-no, and the HHS Office of Inspector General (OIG) has warned against this sort of inappropriate overuse.

Why: Medicare estimates that it could save $538 million by reducing improper use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and $59 million by cutting back on inappropriate modifier 59 use, the HHS Office of Inspector General insists in its 2007 compendium of unimplemented recommendations.

What it means to you: Expect your carriers to scrutinize your modifier 59 claims and to request documentation to support proper modifier use. Look at Other Modifiers First CPT's modifier 59 guidelines say that if another modifier is appropriate, such as if it defines the site of the procedure better, you should use it instead of modifier 59, Cobuzzi says. For example, you should use modifiers LT (Left side) and RT (Right side) to indicate anatomic location.

Example: A urologist performs a bilateral partial nephrectomy for bilateral small renal cell carcinomas. Per CPT and CCI rules, you cannot use modifier 50 (Bilateral procedure) with 50240 (Nephrectomy, partial). You might consider reporting this bilateral surgery scenario using modifier 59: 50240 and 50240-59. But the better coding choice would be 50240-LT and 50240-RT, coding experts say.

Unfortunately, many payers, including some Medicare carriers, have a hard time recognizing these modifiers, so you may end up having to use modifier 59 after all with those carriers. Similarly, Medicare is supposed to pay for multiple units of lesion removal codes, but with some carriers you may have to bill the same code multiple times using modifier 59 instead.  Turn to 59 for Separate Sessions Bottom line: You may use modifier 59 for two separate sessions during which the physician provides services that are normally bundled when done [...]