Question NCCI edits

bharathiT

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Hi,

Please any one clarify the below scenarios,

Same day two procedures performed like wise 20610(Arthrocentesis, aspiration and/or injection, major joint or bursa (shoulder); without ultrasound guidance & 20605(Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (elbow ); without ultrasound guidance).

As per NCCI edits , No Modifiers applicable for these 2 CPT's. Code both CPT's without Modifier.

My Doubt: Both procedures performed at different site, why we dont give 59 Modifier(different procedure or surgery, different site or organ system) even NCCI edit showes no modifier applicable?
 

thomas7331

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There is no need for a modifier to indicate the different site since there is no NCCI edit, and since the two codes have descriptions that clearly show these could not be performed at the same site. One code is for major joints and the other for intermediate joints, so the modifier 59 does not add any additional information since these two procedure would always be at separate sites anyway.
 
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Here I am adding more info which may help you to regard this.

Modifier 51 Multiple Procedures indicates that multiple procedures were performed at the same session.
It applies to:


• Different procedures performed at the same session
• A single procedure performed multiple times at different sites
• A single procedure performed multiple times at the same site

Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.

Indications for use of modifier 59:
• Different session or encounter on the same date of service
• Different procedure distinct from the first procedure
• Different anatomic site
• Separate incision, excision, injury or body part

For the above example,
You can see that procedure names themselves indicates that they are performed on different sites so need to append 59 modifiers again.

Adding more,
I have some data from coding website as follows, which you should read.

Modifier -59
DO
apply it as a last resort. Consider these other options first: -RT (right), -LT (left), or -50 (bilateral procedure). Payers may also accept modifiers -XE (separate encounter), -XS (separate organ or structure), -XU (unusual non-overlapping service), or -XP (separate practitioner). For example, a physician performs an injection in the right and left knees. Report CPT code 20610 with modifier -50 not -59.

DO apply it when there’s a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. For example, a physician trims a callus and trims a toenail on the same toe. The toenail, bed, and surrounding tissues are considered the same anatomical site, says Clements.

DON’T apply it if National Correct Coding Initiative (NCCI) edits prohibit doing so. For example, physicians shouldn’t report a biopsy and excision of the same lesion using modifier -59. They should only report the removal, says Clements. An exception to this is when a physician biopsies the lesion, waits for the pathology results, and then excises the lesion during the same session. In this case, they can report both procedures using modifier -59. If there isn’t any documentation to support the decision to excise the lesion after pathology results were obtained, payers may recoup reimbursement during a post-payment audit, she adds.

Thank You.
Rupesh.
 

mcdream

Networker
Messages
43
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Here I am adding more info which may help you to regard this.

Modifier 51 Multiple Procedures indicates that multiple procedures were performed at the same session.
It applies to:


• Different procedures performed at the same session
• A single procedure performed multiple times at different sites
• A single procedure performed multiple times at the same site

Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.

Indications for use of modifier 59:
• Different session or encounter on the same date of service
• Different procedure distinct from the first procedure
• Different anatomic site
• Separate incision, excision, injury or body part

For the above example,
You can see that procedure names themselves indicates that they are performed on different sites so need to append 59 modifiers again.

Adding more,
I have some data from coding website as follows, which you should read.

Modifier -59
DO
apply it as a last resort. Consider these other options first: -RT (right), -LT (left), or -50 (bilateral procedure). Payers may also accept modifiers -XE (separate encounter), -XS (separate organ or structure), -XU (unusual non-overlapping service), or -XP (separate practitioner). For example, a physician performs an injection in the right and left knees. Report CPT code 20610 with modifier -50 not -59.

DO apply it when there’s a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury. For example, a physician trims a callus and trims a toenail on the same toe. The toenail, bed, and surrounding tissues are considered the same anatomical site, says Clements.

DON’T apply it if National Correct Coding Initiative (NCCI) edits prohibit doing so. For example, physicians shouldn’t report a biopsy and excision of the same lesion using modifier -59. They should only report the removal, says Clements. An exception to this is when a physician biopsies the lesion, waits for the pathology results, and then excises the lesion during the same session. In this case, they can report both procedures using modifier -59. If there isn’t any documentation to support the decision to excise the lesion after pathology results were obtained, payers may recoup reimbursement during a post-payment audit, she adds.

Thank You.
Rupesh.
Rupesh- This info & your explanation is very helpful!
Do you have modifier 25 examples you could share as well?
Thank you!!
 
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