fredcpc
Guru
Always is a strong word. So, is modifier always used if you have two CPT codes that are labeled "separate procedure." Are there any exceptions?
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Wiki Modifier 59 with two "separate procedures"
- Thread starter fredcpc
- Start date
btadlock1
Guest
No!
You ONLY bill CPT's labeled (separate procedures) when they are the only thing done, or there is STRONG evidence that it is unrelated to ANY other procedure billed that day. IF medical records support biling the code separately (and that's a HUGE if), then it would require a 59 modifier to acknowledge that it's a distinct procedural service (yes, it's the 59 every time). Do NOT just tack one on to get the code paid; that could end up costing more in the end if you were audited. Please see this artice:
https://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdfl
You ONLY bill CPT's labeled (separate procedures) when they are the only thing done, or there is STRONG evidence that it is unrelated to ANY other procedure billed that day. IF medical records support biling the code separately (and that's a HUGE if), then it would require a 59 modifier to acknowledge that it's a distinct procedural service (yes, it's the 59 every time). Do NOT just tack one on to get the code paid; that could end up costing more in the end if you were audited. Please see this artice:
https://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdfl
Last edited:
btadlock1
Guest
I should clarify, though...
You would need the 59 modifier every time you bill a code labeled (separate procedure) with a more comprehensive code on the same date, even if they don't seem related, in order for the code to be accepted by commercial payer claims edit software.
A good example is 94150 (vital capacity), with an office visit like, 99213. Vital capacity is not routinely part of the office visit, but without a 59 modifier, insurer's using McKesson's claims edit software will deny 94150. (If you have access to Cigna or BCBS's provider websites, or Availity, you can see the rationale for the denial with their claim edit tools, and you can also see that it will allow payment with a modifier.
I forget other people don't just deal with commercial insurers specifically...sorry...Thinking in commercial-only terms is a habit I forget about having...
You would need the 59 modifier every time you bill a code labeled (separate procedure) with a more comprehensive code on the same date, even if they don't seem related, in order for the code to be accepted by commercial payer claims edit software.
A good example is 94150 (vital capacity), with an office visit like, 99213. Vital capacity is not routinely part of the office visit, but without a 59 modifier, insurer's using McKesson's claims edit software will deny 94150. (If you have access to Cigna or BCBS's provider websites, or Availity, you can see the rationale for the denial with their claim edit tools, and you can also see that it will allow payment with a modifier.
I forget other people don't just deal with commercial insurers specifically...sorry...Thinking in commercial-only terms is a habit I forget about having...
fredcpc
Guru
Two Separate procedures and mod 59
Thank you, great response and article. But may I make sure that I understand you? here is the situation:
Px#1: Separate Procedure
Px#2: Separate Procedure with mod 59
Is this correct? Or if not, how would you code it?
I appreciate your patience and help.
Thank you, great response and article. But may I make sure that I understand you? here is the situation:
Px#1: Separate Procedure
Px#2: Separate Procedure with mod 59
Is this correct? Or if not, how would you code it?
I appreciate your patience and help.
btadlock1
Guest
No problem...I'd have to know the specific codes, and the primary diagnosis to tell you...
FTessaBartels
Guest
Please post the scrubbed operative note
When asking a question such as this it is always best to post the scrubbed operative note (i.e. remove any patient-identifiers). Just as you cannot code without seeing the actual note, we cannot give you accurate advice without actually seeing the note.
Hope that helps.
F Tessa Bartels, CPC, CEMC
When asking a question such as this it is always best to post the scrubbed operative note (i.e. remove any patient-identifiers). Just as you cannot code without seeing the actual note, we cannot give you accurate advice without actually seeing the note.
Hope that helps.
F Tessa Bartels, CPC, CEMC
fredcpc
Guru
Thank you for the feedback. You are all right that it does come down the note and you need the specific codes to make the best coding decision. But I had to make a decision on this...It comes to, is mod 59 "always" used in this case? I believe the answer is no, because many times this type of case will require mod 51, which is what I used. Any feedback?
btadlock1
Guest
See the "Separate procedure" section of the surgery guidelines in the CPT book (Green pages). It says to use a 59 modifier on "separate procedure" codes to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. The guidelines imply that anytime you bill a code with that designation with other services, you should append a 59 modifier to it.
See this article on Modifier 51...
http://www.medicalbillingcptmodifiers.com/2010/08/medicare-modifier-51-multiple-surgery.html
See this article on Modifier 51...
http://www.medicalbillingcptmodifiers.com/2010/08/medicare-modifier-51-multiple-surgery.html
fredcpc
Guru
But can you say, "always" a mod 59 for two separates? It is not a part of a more comprehensive px, and we have multiple procedures.
btadlock1
Guest
This should answer your question, I believe...
http://www.codingandcompliance.com/news/NewsArticleFiles/MultipleSurgProcedures.pdf
It's from 2004, but it's still applicable. It gives examples of when to use 51 and when to use 59.
http://www.codingandcompliance.com/news/NewsArticleFiles/MultipleSurgProcedures.pdf
It's from 2004, but it's still applicable. It gives examples of when to use 51 and when to use 59.
Cpc
I work for an ER physician billing company as an A/R Specialist. The billers have been appending modifier 59 to CPT code 93010 along with the ER visit 99282-99285. Is this a correct use of the modifier to get the 93010 paid or should there just be a modifier 25 appended to the visit? Many insurers are denying payment stating that the 93010 is part of another service.
Merlinda Craig, CPC
I work for an ER physician billing company as an A/R Specialist. The billers have been appending modifier 59 to CPT code 93010 along with the ER visit 99282-99285. Is this a correct use of the modifier to get the 93010 paid or should there just be a modifier 25 appended to the visit? Many insurers are denying payment stating that the 93010 is part of another service.
Merlinda Craig, CPC
btadlock1
Guest
It's probably something else that's being billed, because it shouldn't bundle to the E/M...are you billing another type of EKG, like 93000, or another service from the medicine section?
IpshitaB
New
43235 and 31505
Hi,
Can we bill the two CPT's 43235 and 31505 with Mod-59? If not, please elaborate the medical reason behind it. As per Encoder these two CPT's are Separate Procedures, but no modifier is allowed.
Kindly assist.
Hi,
Can we bill the two CPT's 43235 and 31505 with Mod-59? If not, please elaborate the medical reason behind it. As per Encoder these two CPT's are Separate Procedures, but no modifier is allowed.
Kindly assist.
cgaston
True Blue
The provider has to move the scope past the larynx in order to performed the EGD; the laryngoscopy is a part of the EGD and that is why it is not separately payable.