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modifier 59 - I would like to find out

kdm

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I would like to find out if you can you use modifier 59 for a tonsillectomy when the surgeon does this procedure at the same time as sinus surgery? It seems to me that we should be able to. Do you all do this and does insurance pay.

Thanks, Kim
 

jackjones62

Expert
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259
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Niantic, CT
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Tonsillectomy w/Sinus

Of course you can bill a tonsillectomy with sinus surgery, neither one is inherent to the other, they are separate issues. It's your call on whether to use mod 59 or 51, personally I would use 51 as the diagnosis alone separates the procedures. To me, utilizing mod 59 usually indicates that in certain situations the codes being used could be deemed as related, but, mod 59 is telling the carriers, no, in this situation they are separate. Does that make sense?

Good Luck.

JB-CT
ENT
 

kdm

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thanks, I didn't make myself clear

I didn't make myself clear. These two are different procedures, so when using modifier 59 with the tonsillectomy shouldn't the insurance pay out the tonsillectomy at 100%?

Thanks, Kim
 

Candice_Fenildo

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Stuart Sailfish Chapter
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Kim, That would all depend on your carriers prcing rules. when we contracted with certain insurance companies, we made sure that we had carve outs on certain procedures. especially FESS. so that we would not get thw multiple procedure reductions
 
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Milwaukee WI
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Separate pre-op and post-op?

You ask: These two are different procedures, so when using modifier 59 with the tonsillectomy shouldn't the insurance pay out the tonsillectomy at 100%?

No, they shouldn't ... because you won't be doing separate pre and post-op care.

Remember, the reimbursement for a surgical procedure inlcudes the pre-op visit (day of or day before surgery, unless Decision for surgery), and post op care. If multiple procedures are performed in the same operative session, the multiple surgery discount will apply, because the pre- and post-op care will be handled together.

F Tessa Bartels, CPC, CPC-E/M
 
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