Urology Coding Alert

Focus on the word “repeat” for correct coding. 

If you are confused by recent commotion over a little noticed announcement that some Medicare contractors posted last fall regarding modifier 59 (Distinct procedural service), you are not alone.  

Several Part B payers have started rejecting some claims with modifier 59 based on guidance that went into effect on July 1, 2013 stating that you cannot use modifier 59 for repeat procedures. If your claims have fallen victim to this directive or you are braced for future denials, take a look at these tips to keep your claims on the up and up. 

Review the Payer Guidance

Several Medicare contractors have published their own guidance on this modifier 59 hot topic. Some examples include:

Noridian: “Per a system-process change as of 07/01/13, modifier 59 is no longer considered a valid repeat modifier. Procedures billed with modifier 59 will be denied as exact duplicates.” (www.noridianmedicare.com/partb/claims/alerts/082313.html).

WPS: “Wisconsin Physician Services (WPS) Medicare has a large number of claims denying for incorrect Modifier 59 usage. WPS Medicare researched these denied claims and found that Modifier 76 would be the appropriate modifier to use for several of the denials.” (www.wpsmedicare.com/j5macpartb/resources/modifiers/modifiers59and76.shtml).

Cahaba: “Claims billed with the same procedure code two or more times for the same date of service, should be submitted with the appropriate repeat procedure modifier rather than using Modifier 59.” (www.cahabagba.com/news/changes-to-modifier-59-important-notice).

Looks at 76 When You See ‘Repeat’

While many coders interpreted the payer policies as saying they would deny any modifier 59 claims, the focus of these denials is really on repeat procedures — that is, the same code reported for the same session for the same patient by the same provider. 

Medicare contractors are encouraging practices to use modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or modifier 91 (Repeat clinical diagnostic laboratory test) instead of 59 for repeat procedures. For example, Noridian states “To avoid these denials on repeat procedures, you may bill using 

a 76 or 91 modifier, whichever is most appropriate.”

“Medicare now wants you to use modifier 76 alone when you do repeat exact duplicate services on the same day,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

“In my opinion, this isn’t new guidance,” says Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. “Modifier 59 has never been meant for repeat procedures. It is meant for separate sessions or separately distinct procedures, not repeat procedures.”

The trouble for coders is that no entity has defined what a repeat procedure really is, Kater explains. Some coders argue that performing the same procedure for multiple locations within the same organ (for example, in the same kidney) during the same procedure really does warrant modifier 59 rather than modifier 76, and that modifier 76 is meant for times when the urologist must repeat the same procedure in the same area. An example of such a scenario would be an initial procedure, such as a renal artery thrombectomy (removal of a clot from the renal artery), which must be repeated later that same day by the same surgeon when the clot reforms. 

If payer software is set up to simply deny the same code reported twice on the same claim with modifier 59, you may face denials of legitimate separate procedures. 

“Rules are in place to allow proper billing for services provided, and those who follow the rules properly should be paid appropriately,” says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore. “CMS itself has published several recent articles about proper use of the 59 modifier (distinct and separate but non-adjacent lesion, different approach, and no other modifier is appropriate, etc.), and then merely denying the modifier is in direct contrast to the recent publications.”

Best bet: You should use modifier 59 only when you are seeking to unbundle a Correct Coding Initiative (CCI) edit and there is no other more fitting modifier.

Learn Your Payer’s Interpretation

Because payers can interpret things differently, you need to know the payer you are billing and how that payer wants you to bill each type of scenario, Ferragamo says. 

“Providers need to understand their local carrier rules and interpretations of correct modifier use,” Rubenstein says. “In the case of Noridian, it states that modifier 76 should be used. Modifier 76 is repeat procedure by the same physician, which was intended to show if a procedure had to be repeated by the same physician on the same date.  However, Noridian chose to interpret it as they saw fit.”

Some common urology scenarios may be affected by the modifier 59 guidance. Example include cryoablation of two separate (non-adjacent) lesions of the same kidney, a laparoscopic partial nephrectomy of two non-adjacent lesions in the same kidney, ureteroscopy and laser lithotripsy of a stone in the ureter and a stone in the kidney(separate organs), Rubenstein says. 

Bottom line: “No matter how CMS intended the modifiers to be used or how we were taught or interpret them, we need to use the modifier that the payer wants, and how they interpret the rules,” Rubenstein says. “If a payer prefers the 76 modifier based upon their interpretation and their publications, then use that modifier if it is an appropriate and supported by correct documentation.”