Wiki Modifier 59 with Conscious sedation codes

[cplatt688]

Can someone direct me to some literature explaining or can someone explain to me why sometimes mod 59 is used with 99152 and other times not? I'm running into this problem on Practicode.

Thank you in advance!

 

[Darlene1960]

I asked Practicode this very question and here is their response. "Modifier 59 has to be appended to 99152 when reported with endoscopy codes such as 43239 (#63) as well as colonoscopies. However, the rules does not apply to other CPT/procedures such as the cardiology procedures…pacemaker 33208."

 

[thomas7331]

Not sure I understand Practicode's response here. Did they provide any additional detail beyond this? I'm not sure a statement like that would carry much weight in an audit.

Generally speaking, modifier 59 is only appropriate when documentation supports a 'distinct procedural service', as per the definition. So if you are assigning modifier 59 to break a bundling relationship between the sedation and another procedural service which already includes conscious sedation, then you are in effect reporting that the sedation service was not a part of that procedure but was for another purpose during that encounter which would be clear from the medical record.

Per the Medicare NCCI Policy Manual, Chapter 11, Section W.6:
Medicare generally allows separate reporting for moderate conscious sedation services (CPT codes 99151-99153) when provided by the same physician performing a medical or surgical procedure except when the anesthesia service is bundled into the procedure, e.g., radiation therapy management.