Wiki New & Confused! Need Help!

[TMB1965]

I am new to Opthalmology coding, and the provider I work for always bills out the 68840-E4,68440-E4-51, 67966,67950-51, 66982-54,67010-54-51. They have all come back denied, because according to the NCCI Edits they are bundled, so you can only use a mod 59 to unbundle them. On the modifier 59 when I read it, it was a little confusing, because it does say for different procedures, but then it says you can only use it for different anatomic sites and different encounters on the same dos. My question is if the provider does the 2 procedures on the same eye can you still use mod 59 as long as you have documentation showing the medical necessity for both procedures? My doctor really doesn't want to use mod 59 and insists on using mod 51, so I'm trying to explain to him he can't. Any help or suggestions on this would be so greatly appreciated. Thank you!

 

[mitchellde]

if a procedure is bundled with another procedure either as a component or as mutually exclusive, then to support unbundling you must show separate site, incision, organ, session. If it is a component of comprehensive edit then all components of the bundled code are already an inherent part of the comprehensive code to forcefully unbundle this with a modifier is double dipping. If it is bundled as mutually exclusive then it is consider impossible to have performed those two procedures at the same location in the same session.
So you see if they are bundled by CCI and you perform the procedures on the same location you cannot unbundle these with the use of any modifier, you select the most comprehensive code and code only that procedure.

 

[TMB1965]

Thank you so much for clearing that up for me! Do you know if there is a cheat sheet card anywhere that will show when you can use a modifier 51 or modifier 59, that I can give my provider?

 

[mitchellde]

Not really a cheat sheet for this. Just know that modifier 51 its only job is to indicated that this was a second procedure performed in the same session. Modifier 59 says that this procedure is separately identifiable from the other procedure due to separate site, incision, organ , or session.
Many payers no longer have the 51 in their edit system as they consider all procedures on the claim were performed in the same session unless you use one of the modifiers that indicate separate session.