Wiki use of cpt 64415 as post op pain management

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Can someone please advise on this case? I was looking at things posted in the forum from a while back and the most recent was dated APR 2007. I was wondering if things had changed. Here is the scenario: Patient has a rotator cuff repair under general anesthesia. In the pre-op area, the CRNA provides and interscalene block (64415) for post-op pain management. I get an edit that code 64415 is a component of the comprehensive 29827 (rotator cuff repair). The information I found in the Forum from APR 2007 said we could attach mod 59 to the 64415 because it was not actually the anesthesia used for the procedure. But, why do I get an edit saying the 64415 is a component of 29827? And, what X mod would be used instead of 59 since we have those four new X mods now? Can anyone tell me if it is appropriate to use a modifier on the 64415 today or no? If so, could you direct me to the documentation I could use to clarify this?
I apologize for the length of this post, but any help would be greatly appreciated. :confused:
 
We currently use a mod 59 with CPT 64415 and have no problem receiving payment for this even when used with 29827.
 
I got information from my director on the new X-ESPU mods. The cheat sheet I got says XE-for separate encounter (different time on same day, different day altogether, patient seen in te morning and then again in the afternoon). At first I thought 64415 would be inclusive in the 29827 becuase it is given for post-op pain relief for the principal procedure that is being done. But, then when I read that XE could be used for "different time on the same day" I got really confused because technically the 64415was done in holding prior to the cut time in the OR. Does anyone know of where I could find documentation to back up either reporting 64415 with the mod or just not reporting 64415 since it is a component of the comprehensive procedure? Any help would be soooo appreciated! thanks so much!
 
REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH ANESTHESIA
Committee of Origin: Economics
(Approved by the ASA House of Delegates on October 17, 2007 and last amended on
October 20, 2010)
1.
INTRODUCTION
ASA has recently received reports of payers inappropriately bundling the placement of epidurals and peripheral nerve blocks for postoperative pain control into the payments for surgical anesthesia services. This is contrary to CPT guidance, CCI edits, Medicare contractors? instructions and the process used to assign base unit values to anesthesia codes. In all probability, this bundling is due to payer confusion regarding the difference between regional anesthesia that is applied as a part of the primary anesthetic as opposed to that which, while placed prior to the onset of anesthesia, is intended primarily to provide postoperative analgesia.
A provider may bill for a regional anesthetic technique as a service separate from the anesthetic if the regional technique is employed primarily for postoperative analgesia and if the following conditions apply:
1.1
The anesthesia for the surgical procedure was not dependent upon the efficacy of the regional anesthetic technique ?
For example, if an interscalene nerve block is placed prior to shoulder surgery to effect prolonged postoperative analgesia, then a general anesthetic would have to be used for the actual shoulder surgery rather than simply I.V. sedation in order to properly report the regional block separately. In this setting, if the patient was provided a block and only sedation was added, then it would be clear that the interscalene block was a part of the primary anesthetic rather than a mode of postoperative analgesia.
1.2
The time spent on pre- or postoperative placement of the block is separated and not included in reported anesthetic time ?
Post surgical pain blocks are most frequently placed before anesthesia induction or after anesthesia emergence. When the block is placed before anesthesia time starts or after it has ended, the time spent placing the block should not be included in reported anesthesia time; this is true irrespective of what level of sedation and monitoring is provided to the patient during that block placement.
1.3
Time for a post surgical pain block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time ?
Time spent on the placement of the post surgical pain block that occurs prior to induction or after emergence is separate and not included in reported anesthesia time. In such cases, it may be necessary to report discontinuous anesthesia time. Sedation given expressly to facilitate placement of the block should not be included in reported anesthesia time.
One excellent means of portraying that the block was a postoperative analgesic is to dictate or record its conduct in the chart in a location separate from the anesthetic record. When documenting, it is important to discuss that the surgeon requested that the anesthesia team participate in the provision of postoperative
REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH
ANESTHESIA
analgesia, that the patient was involved in the process of defining the best plan for such analgesia and that the patient received additional information about the risks and procedures of such therapy and consented to the procedure, separate from the information attendant to informed consent for the anesthetic.
Should there continue to be bundling by a payer of these services, despite following the above guidelines, the practitioner may find the following references of value when corresponding with the payer?s representatives.
2.
CPT GUIDANCE
Some payers may be misinterpreting a portion of the Anesthesia Guidelines found in the CPT book:
?The reporting of anesthesia services is appropriate by or under the responsible supervision of a physician. These services may include but are not limited to general, regional, supplementation of local anesthesia, or other supportive services in order to afford the patient the anesthesia care deemed optimal by the anesthesiologist during any procedure.?
However, the question of regional anesthetic procedures for postoperative pain relief has been addressed multiple times by the AMA in its coding guide, CPT Assistant. The message has always been consistent: when a pain relief procedure does not serve to deliver the primary anesthetic for a surgical procedure, it is separately reportable from an anesthesia service.
2.1 CPT Assistant, Volume 7, Issue 2, February 1997
Anesthesia: Coding for Procedural Services
??An anesthesiologist could perform a therapeutic nerve block for pain management before or at the conclusion of the surgical procedure, or insert a catheter into the spinal column to induce continuous postoperative analgesia for therapeutic pain management. In the latter case, if an epidural catheter is inserted into the lumbar region, report code 62279*. This code includes insertion of the catheter and initial injection of the analgesic medication or fluid mixture that may then be connected to and controlled by an external infusion pump. Subsequent daily monitoring of the patient may be reported separately using an appropriate E/M code or anesthesia code 01996 because code 62279* does not include daily monitoring. Payor coverage and reporting requirements for daily monitoring services may vary.?
*Note: CPT Code 62319 replaced 62279 in 2000.
2.2 CPT Assistant, Volume 8, Issue 7, July 1998
Coding Consultation
?Question: How would you code a pain management service (64400-64530) in conjunction with an operative anesthesia service? The pain management injection (64400-64530) is not the operative anesthesia, but is administered pre, inter, or post- operatively for the purpose of postoperative pain management?
?AMA Comment: It is appropriate to report a code from 64400-64530 in conjunction with an operative anesthesia service if an injection, as described by these codes, was also given. The February 1997 issue of CPT Assistant published an article on anesthesia and the coding of procedural services. Under ?Reporting Additional Procedural Services? it reads: ?Additional procedural services provided in conjunction with basic anesthesia administration are separately reportable and coded according to standard CPT coding guidelines applicable to the
REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH
ANESTHESIA
given code and the respective CPT section (eg, Surgery or Medicine sections) in which they are listed.??Do not code procedural services with anesthesia coding guidelines.?
2.3 CPT Assistant, Volume 11, Issue 10, October 2001
Anesthesia and Postoperative Pain Management
This article discusses the circumstances under which a pain procedure is?and is not?separately reportable from anesthesia care when both services are provided by the same physician.
?It is appropriate to report pain management procedures, including the insertion of an epidural catheter or the performance of a nerve block, for postoperative analgesia separately from the administration of a general anesthetic.
?If, on the other hand, the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone??
2.4 CPT Assistant, Volume 17, Issue 5, May 2007
Coding Communication: Question and Answers
This question and answer addressed how time spent placing nerve blocks for postoperative pain control should be reported.
?Question: Should the time spent placing nerve blocks for postoperative pain control, spinals, arterial lines, etc, be deducted from main anesthesia start and stop times? Would the time spent placing these items need to be deducted from the anesthesia time for the operation? Is there a difference between the arterial line, etc, being placed prior to the patient ?going to sleep? or after in regards to discounting this ?placement? time?
?Answer: The Anesthesia guidelines in the CPT codebook indicate that placement of monitoring devices such as central venous lines, arterial lines, and Swan-Ganz catheters are separately reportable from an anesthesia service. Placement of these monitoring devices have no time associated with them. If a nerve block or epidural is performed for the purpose of postoperative pain management and not as part of the anesthesia for the surgical procedure, then it too is reported separately. When these procedures are performed before the start of anesthesia time, the time spent on them should not be added to the reported anesthesia time because they are separate and distinct from the anesthesia service. If the procedure is performed after induction of the primary anesthetic, it is not necessary to deduct the time spent on the procedure from reported anesthesia time.?
AMA has also provided guidance on the topic in its publication titled Principles of CPT Coding:
?In addition to the physical status modifiers, it may also be appropriate to report other CPT modifiers when codes for procedural services are reported in addition to the basic anesthesia service. Remember, if the anesthesiologist performs other additional procedures, each is separately reportable.
EXAMPLE
A patient undergoing a thoracotomy receives an epidural injection of a local anesthetic for postoperative pain control in addition to the general anesthetic administered through an endotracheal tube.
REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH
ANESTHESIA
In this case, the epidural (62318) is not the surgical anesthetic (00540) and it would be reported separately as an independent procedure. When general anesthesia is administered and epidural or nerve block injections are performed to provide postoperative analgesia, they are separate and distinct services and are reported in addition to the anesthesia code. Whether the block procedure (insertion of catheter; injection of narcotic or local anesthetic agent) occurs preoperatively, postoperatively, or during the procedure is immaterial
EXAMPLE
A patient undergoes a total knee replacement surgery, receiving a regional anesthetic and a post operative pain management agent through the same epidural catheter.
When the block procedure is used primarily for the anesthesia itself, the service should be reported using the anesthesia code alone (01402).. In a combined epidural and general anesthetic, the block cannot be reported separately.
3.
CCI EDITS
The National Correct Coding Initiative (CCI) is a process in which CPT codes are reviewed and analyzed to determine when particular services may or may not be reported together by the same physician for the same patient during a single encounter. The CCI looks for instances of ?unbundling? (reporting the individual components of a service instead of the total service) and for code combinations that would be mutually exclusive of each other. Code pairs that could never be reported together have a modifier status indicator of ?0.? Code pairs that could be reported together under specific circumstances have a modifier status indicator of ?1.?
The CCI permits the reporting of a pain procedure along with an anesthesia service when appropriate (i.e., when the pain procedure is not used as regional anesthesia for surgery). The edits that pair anesthesia with codes used to manage postoperative pain (such as epidurals and brachial plexus, sciatic and femoral blocks) have an indicator of ?1.?
The CCI Policy Manual, Version 15.3, Chapter 2 specifically states
A patient has an epidural block with sedation and monitoring for arthroscopic knee surgery. The anesthesiologist reports CPT code 01382 (Anesthesia for diagnostic arthroscopic procedures of knee joint). The epidural catheter is left in place for postoperative pain management. The anesthesiologist should not also report CPT codes 62311 (injection of diagnostic or therapeutic substance) or 01996 (daily management of epidural) on the date of surgery. CPT code 01996 may be reported with one unit of service per day on subsequent days until the catheter is removed. On the other hand, if the anesthesiologist performed general anesthesia reported as CPT code 01382 and reasonably believes that postoperative pain is likely to be sufficient to warrant an epidural catheter, CPT code 62319-59 may be reported indicating that this is a separate service from the anesthesia service. In this instance, the service is separately payable whether the catheter is placed before, during, or after the surgery. If the epidural catheter was placed on a different date than the surgery, modifier 59 would not be necessary.
The CCI edits and the current CCI Policy Manual are available at http://www.cms.hhs.gov/nationalcorrectcodinited/01_overview.asp
REPORTING POSTOPERATIVE PAIN PROCEDURES IN CONJUNCTION WITH
ANESTHESIA
4.
MEDICARE CONTRACTOR INSTRUCTIONS
Medicare contractors provide coding guidance and instructions to providers in numerous ways. Two common methods are including a specialty-specific billing guide on its Web site and issuing Local Coverage Determinations (LCD). Here are some examples pertinent to this issue:
4.1 NHIC Anesthesia Billing Guide ?
According to the Anesthesia Billing Guide posted on the Web site of NHIC ? a Medicare Part A/B Contractor - available at
http://www.medicarenhic.com/providers/pubs/AnesthesiaBillingGuide.pdf
4.1.1 Pain Management
Pain Management Consultation
Evaluation and management services for postoperative pain control on the day of surgery are considered part of the usual anesthetic services and are not separately reportable. When medically necessary and requested by the attending physician, hospital visits or consultative services are reportable by the anesthesiologist during the postoperative period. However, normal postoperative pain management, including management of intravenous patient controlled analgesia, is considered part of the surgical global package and should not be separately reported.
4.1.2 Postoperative Pain Control Procedures
When provided principally for postoperative pain control, peripheral nerve injections and neuraxial (spinal, epidural) injections can be separately reported on the day of surgery using the appropriate CPT procedure with modifier -59 (Distinct Procedural Service) and 1 unit of service. Examples of such procedures include:
62310-62319
Epidural or subarachnoid injections
64415-64416
Brachial plexus injection, single or continuous
64445-64448
Sciatic or femoral injections, single or continuous
64449
Lumbar plexus injections, continuous
These services should not be reported on the day of surgery if they constitute the surgical anesthetic technique.
NOTE: Modifier 59 requires that the medical record substantiate that the procedure or service was a distinct or separate services performed on the same day.
4.2 National Government Services ? Local Coverage Determination #28529 ?
This Medicare
 
Managing Postoperative Pain Is a Joint Effort



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 In Healthcare Business Monthly Archive

 September 1, 2013

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Coding and documentation should reflect new changes to both surgical and anesthesia reporting.

By Kelly D. Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA

Postoperative pain management (POPM) is a team effort between the surgeon and the anesthesia provider. Changes in coverage affect both surgeons and anesthesia providers, and coders from various specialties should pay attention to new guidance regarding coding and documentation for POPM.

Conditions Apply for Separate
Payment of Post-op Pain

There were verbiage changes in the National Correct Coding Initiative?s (NCCI), Anesthesia Services section, chapter II, pages II-7 through II-12, version 18.0 (effective Jan. 1, 2012) and chapter II, pages II-6 through II-15, version 19.0 (effective Jan. 1, 2013). These changes outline the circumstances under which acute pain management is payable, and emphasize the requirement of documentation from the surgeon requesting assistance from an anesthesia provider.

A recent proposed draft local coverage determination (LCD) by Noridian Administrative Services, LLC, ?Nerve Blockade: Somatic, Selective Nerve Root, and Epidural? (DL33188), regarding POPM indicates, ?Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control.? As written, the Noridian LCD would drastically change the way anesthesia providers are paid for anesthesia services.

Both the American Society of Anesthesiologists (ASA) and anesthesiologists who serve on their state carrier advisory committee (CAC) are working to ensure Noridian has a clear understanding of acute pain management services. Initial responses to comments from contractor medical directors at Noridian during recent CAC meetings suggest there will be significant changes in the current LCD draft?s language; however, coders and anesthesia practices from any state had until July 11, 2013 to submit comments regarding the LCD draft.

The NCCI verbiage changes and the proposed LCD draft are based on the Centers for Medicare & Medicaid Services (CMS) Medicare Claim Processing Manual, chapter 12 ? ?Physicians/Nonphysician Practitioners? premise that postsurgical pain management by the surgeon is included in the global surgical package. The NCCI , however, recognizes the ability of the surgeon to ?request the assistance of the anesthesia practitioner if the degree of postoperative pain is expected to exceed the skills and experience of the operating physician to manage it.? NCCI also indicates POPM procedures may be ?administered preoperatively, intraoperatively, or postoperatively.?

Although post-op pain is the responsibility of the surgeon and payment is bundled into the surgeon?s global fee, anesthesia services may be reported separately if:
?The services are requested by the surgeon for an anesthesia practitioner to provide POPM; and
?Anesthesia for the surgical procedure is not dependent on the efficacy of the regional anesthetic technique.

The ASA Relative Value Guide? (RVG??), 2013 Reporting Postoperative Pain Procedures in Conjunction with Anesthesia (pages 58-65) indicates the following conditions apply:
◦Anesthesia for the surgical procedure was not dependent on the efficacy of the regional anesthetic technique;
◦Time spent on pre- or post-op placement of the block is separated and not included in reported anesthetic time; and
◦Time for a post surgical block that occurs after induction and prior to emergence does not need to be deducted from reported anesthesia time.

The RVG?? also suggests documenting the surgeon?s request; however, according to the NCCI, the ?surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner.? This provision requires a written request from the surgeon, which indicates there must be communication between anesthesia and surgical staff to ensure the requirements for POPM are well documented for each patient on a case-by-case basis.

Code Post-op Pain Procedures

Procedure coding will depend on the site of the injection area and placement of either a block(s) or a continuous catheter. See Table 1 for some of the more common CPT? codes associated with POPM services.

Table 1: Common CPT? codes associated with POPM services




CPT? Procedures
Single Injection

Description



64415

Injection, anesthetic agent; brachial plexus, single



64445

Injection, anesthetic agent; sciatic nerve, single



64447

Injection, anesthetic agent; femoral nerve, single



64450

Injection, anesthetic agent; other peripheral nerve or branch



CPT? Procedures
Continuous Catheter

Description



62318

Injection(s) including indwelling catheter placement, continuous infusion or intermittent bolus of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic



62319

Injection(s) including indwelling catheter placement, continuous infusion or intermittent bolus of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral



64416

Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)



64446

Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement)



64448

Injection, anesthetic agent; femoral nerve, single continuous infusion by catheter (including catheter placement)


The appropriate CPT? code(s) should be appended with modifier 59 Distinct procedural service to signify the service or services were distinct from the anesthesia provided for the surgery.

Remember: If the block/catheter was used for the surgery, the procedure is not separately billable; however, discontinuous anesthesia time may be reported for the time spent placing the block/catheter.

For example: If a carpal tunnel procedure is being performed with a wrist block, a code from the CPT? anesthesia section (01810 Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand plus the anesthesia time for both the anesthesia during the wrist surgery and for placing the wrist block) is reported. A separate code is not reported for the wrist block.

Always check the documentation carefully and ensure you understand the procedure being performed.

For example: Several terms are used to describe a ?brachial plexus? block, such as ?interscalene,? ?infraclavicular,? or ?supraclavicular.? Do not confuse these with codes with a similar sounding description (such as ?suprascapular?).

A ?popliteal? block procedure note, without a description of the anatomy, is not helpful in determining the correct code to report. A ?popliteal fossa? injection is reported with 64445 (sciatic nerve); whereas a ?saphenous popliteal? is reported with 64450 (other peripheral nerve block).

Also, transversus abdominis plane (TAP) blocks do not have a specific procedure code. CPT? code 64450 may be used; however, CPT? code 64425 may be appropriate for TAP blocks performed for inguinal hernia repair when the ilioinguinal/iliohypogastric nerves are anesthetized (Mariano, ?Billing for Regional Anesthesia).? If you are unclear about the services provided, confirm all questionable details.

If ultrasound guidance is used and appropriately documented, CPT? 76942 Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation may be reported separately (with modifier 26 Professional component, if applicable). Documentation of ultrasound alone is not sufficient. According to CPT? non-obstetrical ultrasound coding guidelines, ?Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.? A retrievable image should be available, along with a procedure note describing the ultrasound use for block placement.

When reporting anesthesia, remember that codes obtained from the surgery and radiology section are flat-fee. Although no time is reported separately, documentation must support the time the block was placed (i.e., 7:21 p.m. to 7:34 p.m.) to clearly distinguish it was separate from the reported anesthesia time, when applicable.

Daily Pain Management

Reporting daily management of post-op pain will vary, depending on the services provided. According to the NCCI, ?CPT code 01996 may only be reported for management for days subsequent to the date of insertion of the epidural or subarachnoid catheter.? CPT? 01996 Daily hospital management of epidural or subarachnoid continuous drug administration would not be reported for other types of continuous catheters, such as 64416, 64446, and 64448.

Determine whether the documentation supports an evaluation and management (E/M) service, including the chief complaint (related to post-op pain) and at least two of the three required elements for subsequent hospital care (history, examination, and medical decision-making (MDM)). Keep in mind that if the surgeon has transferred responsibility for POPM to an anesthesia provider, only one physician or qualified healthcare professional should report these services.

For example: If a continuous interscalene catheter is used for POPM, and the catheter is left in place, documentation for the follow-up days should include:

Chief complaint ? You should not be expected to presume POPM.

At least two of the following three components:

a.) History (i.e., location, quality, severity, duration, time, etc.)

b.) Examination (The extent of the examination performed is dependent upon the examiner?s clinical judgment, the patient?s history, and the nature of the presenting problem.) The documentation should reflect whether the catheter site was examined and all pertinent information.

c.) MDM (Is the patient stable, improving, progressing as expected or resolved? Have any problems been addressed? Is the pain being properly managed?)

Because the surgeon has transferred the post-op care to an anesthesiologist, the surgeon should not report these services in addition to the anesthesia provider. Remember also to check with the payer, as policy may limit the number of reportable or covered follow-up days.

ICD-9-CM Coding

Acute pain diagnosis codes are separately identified in section 338 of ICD-9-CM?although, there is confusion regarding reporting a diagnosis code from this section.

According to ICD-9-CM guidelines, ?Routine or expected postoperative pain immediately after surgery should not be coded.? The guidelines also state, however, ?If pain control/management is the reason for the encounter, a code from category 338 should be assigned as the principal or first-listed diagnosis? and ?may be reported as the principal or first-listed diagnosis when the stated reason for the admission/encounter is documented as postoperative pain control/management.?

Because routine pain management is provided by the surgeon, it?s my opinion that a category 338 code should be reported when anesthesia is requested to provide POPM. In the aforementioned Noridian draft policy, however, these diagnosis codes are listed as Group 1 and identified with an asterisk (*) to indicate, ?Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage the pain? (see Table 2). Again, please note those involved in the CAC process believe the Noridian draft policy is likely to be revised substantially.



Table 2: Group 1 medical necessity ICD-9-CM code



338.11*

Acute pain due to trauma



338.12*

Acute post-thoracotomy pain



338.18*

Other acute postoperative pain



338.19*

Other acute pain



786.50*

Unspecified chest pain




Historically, anesthesia practices have relied on documentation by the anesthesia provider to support the surgeon?s request for POPM, such as a procedure note or anesthesia record indicating the surgeon?s request. In the current environment, you should rely on the documentation guidelines as outlined in the NCCI and the recommendations listed by the ASA. Documentation in the medical record must support the surgeon?s transfer of care. This requirement means anesthesia practitioners should request written, rather than verbal, communication.


Kelly D. Dennis, MBA, CPC, CPC-I, CANPC, ACS-AN, CHCA, has more than 30 years of experience in anesthesia coding. She serves on the Board of Medical Specialty Coding as lead advisor for the anesthesia board. Dennis is president of Perfect Office Solutions, Inc. She is a member of the Ocala, Fla., local chapter.

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It is to my understanding that medical procedures, such as nerve blocks, can only be administered by anesthesiologists. This may be your problem.

Are you billing for the surgeon or anesthesiologist?

I bill out anesthesia and only anesthesiologists do blocks. I put them on separate claims with a 59 modifier with no problems.
 
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