Wiki Multiple procedures and modifier 59---Help!!

[wfriddle]

My providers are not understanding the logic behind some of the reimbursement policies out there and I am having a hard time coming up with a straight answer that everyone is happy with. I understand there is a list of procedures that are subject to the multiple procedure reduction but does that mean that those procedures will never pay at 100% when billed with another more expensive procedure? If so what is the point of modifier 59? Is it only to overide a mutually exlusive relationship of procedures? If I have two procedure that are perfomed by different methods on different organ systems does that not in fact qualify as two distinct procedures? I am confused and the more research I do the more confused I get. Can anyone help with billing multiple procedures and when they should and shouldn't be reduced? I know my providers do not want to be missing out on money for services they performed but I also don't want to waste a whole lot of time on a hopeless cause. I want to make sure that I am billing correctly and getting my providers the money they deserve and have the knowledge to explain to them when I can not. I am struggling with this one.

 

[EricaR]

In my understaing modifier 59 will not prevent multiple procedure reduction. Modifier 59 allows your cpt to bypass the edit that would otherwise cause that code to deny as inclusive.

 

[capricew]

My providers are not understanding the logic behind some of the reimbursement policies out there and I am having a hard time coming up with a straight answer that everyone is happy with. I understand there is a list of procedures that are subject to the multiple procedure reduction but does that mean that those procedures will never pay at 100% when billed with another more expensive procedure? If so what is the point of modifier 59? Is it only to overide a mutually exlusive relationship of procedures? If I have two procedure that are perfomed by different methods on different organ systems does that not in fact qualify as two distinct procedures? I am confused and the more research I do the more confused I get. Can anyone help with billing multiple procedures and when they should and shouldn't be reduced? I know my providers do not want to be missing out on money for services they performed but I also don't want to waste a whole lot of time on a hopeless cause. I want to make sure that I am billing correctly and getting my providers the money they deserve and have the knowledge to explain to them when I can not. I am struggling with this one.

To add to the other comment,
if two procedures bundle as being mutually exclusive, there is no modifier that can be billed to unbundle them. Mutually exclusive means that there are no circumstances in which it would be appropriate to bill the two procedures together. Therefore, only one will be paid regardless of any modifiers used to unbundle them.

 

[capricew]

One more thing,
to clarify- modifier 59 is used to unbundle two codes that normally bundle when you can prove they were done on a different site, different incision, different session different provider or surgery, etc.....
your documentation must clearly show the different site, incision or session in order for you to use this code.

for example
64483 LT and 20610 - these two codes bundle normally. However if my documentation shows that 64483 Lt was done at L5-S1 and my documentation shows that 20610 was done on the Rt shoulder then i can bill them both because they are two completely different sites that are no where near each other and i would bill this way:
64483-LT
20610-59,RT
(My CCI code editor shows that these two codes are conflicting with 64483 as column 1 and 20610 as a column two code. But, my code editor put a 1 on the conflict for 20610 and the one indicates that it can be unbundled if i have an appropriate modifier and sufficient documentation to do so. In this case my modifier 59 is placed on the column two code which is 20610.)

This, however, does not mean that you will be paid at 100% on the second code (20610) listed on your claim. It just means it is payable if your modifier and records support unbundling it. That being said - most insurances only pay 50% of the allowable on the second line item billed.

There is however a list of codes in Appendix E of your cpt code book that lists all the codes not subject to the 50% reduction. For instance, code 63650. This code pays at 100% on the first line billed and the second line billed because it is considered device intensive. Medicare does not pay for implants, so this procedure is device intensive meaning the payment the surgery center gets has the cost of the device factored into the same price that they get paid as a center. No separate reimbursement for the device/implant. That being said, as a surgery center, if two leads are placed they would bill 63650 on line one and 63650 on line two and be reimbursed at 100% for each line billed because 63650 is modifier 51 exempt. (also of note 63650 cannot be billed in units)

When you run CCI edits on two codes if they come up with a conflict showing a zero indicator - this is telling you they are mutually exclusive and can never be billed together under any circumstances.

Hope this helps!