What modifier do i use?

tpayne129

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When I bill Cahaba/TN Medicare for the professional procedure 64635 with the add-on code 64636 x2 units what modifier do I use? They deny it if I bill with 2 units (stating invalid units) so I have to separate it 64635,64636,64636. If I don't use a modifier they deny the second 64636 as a duplicate. What is the appropriate modifier?
 

dwaldman

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I assume the three levels was on one side. If it was bilateral, they potential only allow two levels performed bilaterally for RFA procedures of the spine. Below I found an article that states that they don't specifically limit the use of modifier 59 to code pairs that have NCCI code edit. So potentially you could use modifier 59. They also mention modifier 76 which could be another option. Technically you would assume you should be able to bill 64635 64636 X 2 with no issues with quantity 2.


Correct Usage of Modifier 59

Posted May 2, 2012 in Part B


This article replaces and rescinds any previous communication from Cahaba regarding the usage of Modifier 59 and Modifier 76. Please begin following these guidelines immediately.

***Note: If providers need to take any action to correct the claim denials associated with Modifier 59 that occurred during October through December 2009, Cahaba will issue specific instructions to the providers. No action is required by the providers at this time.

MODIFIER 59 is defined as a DISTINCT PROCEDURAL SERVICE: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service performed on the same date, see modifier 25.

Modifier 59 is to be used as the modifier of last resort and “only if a no more descriptive modifier is available”. Modifier 59 cannot be used to unbundle a CCI code pair that has a modifier indicator of ‘0’.

Modifiers to consider before using Modifier 59 include:

50—Bilateral procedure: Use this modifier to indicate that the same procedure is performed at the same operative session on bilateral anatomical body parts (ex: knees, ankles, eyes, ears, etc). Note: This modifier should not be used with skin lesion removal. Unless otherwise indicated in the CPT listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate 5 digit code.

76—Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service. This is a repeat of the same procedure, on the same patient, by the same physician.
 

KMCFADYEN

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I code for pain management
we would bill Medicare like this:
64635
64636 76,59
64636 76,59

*we also use the modifier for the side on these
 
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Erie, PA
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Billing rf to medicare

I have billed 64635 and 64636 x 2 units using the anatomical modifier. Billing 64636 x 2 is for 2 different levels so the 76 is not needed as that is for a repeat of same procedure, so if you are just coding another level just the 59 would be needed. Medicare is now only allowing the modifier 59 to be used 1 time per encounter. Like I said, I have had them pay without the use of modifier 59. Hope this helps. You also may want to check with the carrier as some of them want things billed differently
 
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