Wiki modifier 59

[lbarbar]

hello all,

now i am facing a problem with modifier 59 ....


modifier 59 is used in these cases:

1.different session

2. different procedure or surgery

3. different site or organ system

4. separate incision/excision

5. separate lesion, or separate injury



i understand all the above cases except the second one .......... what do they mean by different procedure or surgery? i mean they are always different procedure that we need to add a 59 to one of them........


i have this example .......... a patient had a Lap BSO and appendectomy .......... according to NCCI edit these are bundled procedure ....... so can i use mod 59 in this case? since they are different procedure ?


its really confusing .........


hope you can help me to understand mod 59 better


thank you



Linda

 

[lbarbar]

can any one help please?

 

[thomas7331]

When you run into problems with whether or not to use the modifier 59 to unbundle, the best starting point is to review the NCCI Policy Manual. The manual explains the rationale for many (but not all) of the edits and why the code pair are set up to require a modifier. You can find a link to the manuals here:

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

For your particular example, take a look at Chapter VI - Digestive System. Section E for abdominal procedures, paragraph 3, states "A medically necessary appendectomy may be reported separately. However, an incidental appendectomy of a normal appendix during another abdominal procedure is not separately reportable." And further down, in Section F for laparoscopic procedures, paragraph 5, "CPT code 44970 describes a laparoscopic appendectomy and may be reported separately with another laparoscopic procedure code when a diseased appendix is removed. Since removal of a normal appendix with another laparoscopic procedure is not separately reportable, this code should not be reported for an incidental laparoscopic appendectomy." So I take this to mean it would be appropriate report the appendectomy with the 59 modifier if the provider documented that it was diseased and necessary for this patient, but not if it was done incidentally in the course of the primary procedure.