Wiki Modifier 59 - bariatric practice

[johanna.sylvester@nyumc.org]

Our office is going back and forth regarding the following issue:

We are a primarily bariatric practice, however my surgeon typically repairs a hernia (cpt code 43281) while she is there is she notices it. Can we bill cpt code 43770 with 43281 (with modifier 59)? or should this be modifier 51?

 

[thomas7331]

According to the NCCI manual "If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair...is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately." As you describe it above, the hernia repair is both incidental and not through a separate incision, so I don't think it meets the requirements for a modifier 59 as described here by CMS.