Wiki Modifier 59 - billing a bilateral

[medsolutions]

We're billing a bilateral DIEP flap (breast reconstruction) with modifier 59 on the opposite breast, our argument is that the surgeon needs to perform a separate incision and a separate reconstruction on the opposite breast. However, the insurance company is paying it as if we had used a 51 or a 50 modifier. They pay 100% on the first breast and only 50% on the second. Am I wrong, in thinking that modifier 59 is not only appropriate but he is entitled to get reimbursed at 100% for both, since basically he has to do the same surgery twice. Can someone enlighten me?

 

[Lujanwj]

Multiple Procedure Rules still apply to -59. Patient is already under anesthesia, prep'ed, and in global care (for pre/post op). Modifier -59 just shows it was separate and distinct procedure from the other procedure.

Consider this, when Dr removes a two benign lesions of the same size from the trunk you code it 11400 11400-59. Modifier -59 indicates that it's not an accidental duplicate claim. When you're reimbursed you'll be hit with multiple procedure rule.

With that being said, you are coding it incorrectly. 19364 is a bilateral procedure so you should be using -50. Using -59 incorrectly can call an audit on you so be very careful with it.

Hope that helps