Were procedures 72170: x-ray, pelvis 1 or 2 views, in addition to 73502: x-ray hip, unilateral, with pelvis when performed, 2-3 views, both separately performed on the same DOS, during the
same encounter in the radiology department? Modifier 59 can be used with 72170 but it may not be appropriate to do so if pelvic x-rays were performed during the same session as the hip x-rays.
Or were there 2 separate encounters in the radiology department and each of these procedures were performed during separate encounters? For example, did the provider order the pelvic x-ray 72170, which is the first encounter in the radiology department, after the pelvic x-rays were taken did something change clinically that the physician (or another physician) subsequently order the hip x-ray 73502, and because the pelvic x-rays were already performed, only the hip x-ray was performed in second encounter in the radiology?
The part of full definition of modifier 59 states:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, 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 individual.
If there was only 1 encounter in the radiology department, I think you are going to have a hard time justifying using modifier 59 on 72170. What is your coworker's rationale for using modifier 59, is it just because she ran it through the scrubber and found that the NCCI edit could be overridden by using it?
I'm having a hard time coming up with a rationale for considering the pelvic x-rays distinct separate services from the hip x-rays if there was only one encounter in the radiology department and the pelvic x-rays were performed at the same time as the hip x-rays, I believe it is appropriate to only bill 73502. If you want to bill both procedure codes, it would not be appropriate to use modifier 59 with 72170 based on the definition of the modifier and you should expect 72170 to be denied as bundled.
As someone who works for an insurance company and sees a lot of inappropriate modifier 59 use, I would find this claim scenario questionable. I would question the billing of these procedures on the same DOS even with modifier 59 appended to 72170. If modifier 59 is being used frequently on claims for your provider(s), you may find your provider being selected for pre-payment or post-payment review/audit of claims with modifier 59 on them.
If there were 2 separate encounters in the radiology department and the pelvic x-ray was performed first and then the hip x-ray was performed, then use of a modifier to indicate the services are distinct and separate, it would be appropriate to use modifier 59. However, I would suggest considering modifier
XE-Separate encounter, a service that is distinct because it occurred during a separate encounter, rather than 59 because it is more specific as to why the procedures are distinct separate services/procedures. Modifier XE is on the list of modifiers that may be used with 72170.
Were procedures 72170: x-ray, pelvis 1 or 2 views, in addition to 73502: x-ray hip, unilateral, with pelvis when performed, 2-3 views, both separately performed on the same DOS, during the
same encounter in the radiology department? Modifier 59 can be used with 72170 but it may not be appropriate to do so if pelvic x-rays were performed during the same session as the hip x-rays.
Or were there 2 separate encounters in the radiology department and each of these procedures were performed during separate encounters? For example, did the provider order the pelvic x-ray 72170, which is the first encounter in the radiology department, after the pelvic x-rays were taken did something change clinically that the physician (or another physician) subsequently order the hip x-ray 73502, and because the pelvic x-rays were already performed, only the hip x-ray was performed in second encounter in the radiology?
The part of full definition of modifier 59 states:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, 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 individual.
If there was only 1 encounter in the radiology department, I think you are going to have a hard time justifying using modifier 59 on 72170. What is your coworker's rationale for using modifier 59, is it just because she ran it through the scrubber and found that the NCCI edit could be overridden by using it?
I'm having a hard time coming up with a rationale for considering the pelvic x-rays distinct separate services from the hip x-rays if there was only one encounter in the radiology department and the pelvic x-rays were performed at the same time as the hip x-rays, I believe it is appropriate to only bill 73502. If you want to bill both procedure codes, it would not be appropriate to use modifier 59 with 72170 based on the definition of the modifier and you should expect 72170 to be denied as bundled.
As someone who works for an insurance company and sees a lot of inappropriate modifier 59 use, I would find this claim scenario questionable. I would question the billing of these procedures on the same DOS even with modifier 59 appended to 72170. If modifier 59 is being used frequently on claims for your provider(s), you may find your provider being selected for pre-payment or post-payment review/audit of claims with modifier 59 on them.
If there were 2 separate encounters in the radiology department and the pelvic x-ray was performed first and then the hip x-ray was performed, then use of a modifier to indicate the services are distinct and separate, it would be appropriate to use modifier 59. However, I would suggest considering modifier
XE-Separate encounter, a service that is distinct because it occurred during a separate encounter, rather than 59 because it is more specific as to why the procedures are distinct separate services/procedures. Modifier XE is on the list of modifiers that may be used with 72170.
Thank you for that very detailed and very useful reply. She only used -59 because it came up on the scrubber and the NCCI Edit told her there was an override modifier. I believe the x-rays were performed during the same session and ordered at the same time.
