Wiki Modifier 59 being billed on every line

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dillon091909

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I work for a remote medical billing company who manages 15 clinics. They bill every CPT line with modifier 59 and I think this is wrong. I have been written up because I had taken off the modifier 59 of a surgery when per the NCCI it says none of the codes are bundling. I always check the CCI in AAPC to verify this. The Surgery was for CPT 12032, 11404 and 11200. The billing manager had billed each line with a modifier 59. CPT 11200 was denied as bundling so I deleted the modifier 59 from this line and the code reprocessed and paid.

I need to find out why the billing company says it's ok to put modifier 59 on every code? I don't think this is right. Insurances are flagging us for the operative notes for each surgery since every line has the modifier 59.

Ex:
19380-RT-59
19370-RT-59
19318-LT-59
19316-RT-59
19120-59
14301-59
14301-59
 
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Of course this is wrong, but unfortunately many providers do this to avoid denials rather than taking the time to do it correctly. You could let them know that this kind of pattern will likely flag the providers for audit by payers - that might help to get their attention. Keep in mind though that whether or not this is fraudulent would require a review of the medical records to see whether or not the improper use of modifiers is actually causing overpayments.
 
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UnitedHealthcare is one of the insurance's that flags every single surgery for op notes as every line has the modifier 59. The billing company knows this but still puts the modifier 59 on every line.
 
Adding modifier 59 to everything would be fraudulent billing. Get away as far and as fast as you can. What they are doing is an attempt to get around bundling.
 
You've edited and changed your question since my last response, but I'd still say the same thing. It's incorrect to do this. Adding the modifier to every line may or may not cause a denial or an overpayment depending on the situation, but regardless, modifier 59 means something very specific and it can't be just added or removed from a code without reviewing the physician's documentation to validate whether or not its use is appropriate. Adding or removing a modifier is equivalent to changing the coding. Do the practices know that the billing company is changing their coding? If not, then the billing company is putting those practices at a very serious financial and compliance risk and the practices should be informed.
 
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I was told by the owner of the billing company that both the providers and the billing company want the modifier 59 on every line so they can get paid. To me this is fraud.
 
That is without a doubt fraud, 100% violation of the federal false claims act too if any of these are government payers. Do you have compliance officer you can go to? Id start typing up your resume and getting out of there ASAP before the feds come knocking at the door. If payers have already started requesting notes on every claim they know full well what is going on.
 
I would be cautious about accusing people of fraud without knowing all of the facts. This is a sloppy practice that could indeed cause inappropriate payments, but without looking at the codes submitted and the documentation, you cannot say that definitively.

I worked for a doctor once who did this. He knew the bundling rules and he never tried to bill for a service that was bundled - he always chose the correct CPT codes. But he just could never keep it straight in his head which ones were the column 1 codes and which were the column 2 codes, so he put the modifiers on all of them. We had to go in behind him and fix the modifiers, but nothing he ever did would have caused an overpayment. The application of the modifier alone does not cause a payment error - it's only when it is applied to a service that is bundled and should not be paid separately.
 
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thomas7331 said:
I would be cautious about accusing people of fraud without knowing all of the facts. This is a sloppy practice that could indeed cause inappropriate payments, but without looking at the codes submitted and the documentation, you cannot say that definitively.
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Ok, ill put it this way, if the blanket policy is to add modifier 59 to all claims regardless of whether its appropriate based on the physicians notes would be a 100% fraudulent billing. From the way it was initially worded the application of modifier 59 is not being done on a case by case basis but across the board.
 
It's a small medical billing company that started back in 2012. I asked and they do not have a medical compliance officer. The two owners stated that they can be the compliance officers and I told them no they can't as they are the founding partners and managers.
 
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