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Thread: modifier 59 - I would like to find out

  1. #1

    Default modifier 59 - I would like to find out

    AAPC: Back to School
    I would like to find out if you can you use modifier 59 for a tonsillectomy when the surgeon does this procedure at the same time as sinus surgery? It seems to me that we should be able to. Do you all do this and does insurance pay.

    Thanks, Kim

  2. #2
    Join Date
    Apr 2007
    Duluth, Minnesota


    check with the CCI Edits for the codes you're using - see if they can be billed together or not.
    Donna, CPC, CPC-H

  3. #3

    Default Tonsillectomy w/Sinus

    Of course you can bill a tonsillectomy with sinus surgery, neither one is inherent to the other, they are separate issues. It's your call on whether to use mod 59 or 51, personally I would use 51 as the diagnosis alone separates the procedures. To me, utilizing mod 59 usually indicates that in certain situations the codes being used could be deemed as related, but, mod 59 is telling the carriers, no, in this situation they are separate. Does that make sense?

    Good Luck.


  4. #4

    Default thanks, I didn't make myself clear

    I didn't make myself clear. These two are different procedures, so when using modifier 59 with the tonsillectomy shouldn't the insurance pay out the tonsillectomy at 100%?

    Thanks, Kim

  5. #5
    Join Date
    Apr 2007
    Stuart Sailfish Chapter


    Kim, That would all depend on your carriers prcing rules. when we contracted with certain insurance companies, we made sure that we had carve outs on certain procedures. especially FESS. so that we would not get thw multiple procedure reductions
    Candice Fenildo, CPC, CPMA, CPB, CENTC, CPC-I
    AAPC Chapter Association Board of Directors ( Chair)
    Region 6, Wisconsin, Minnesota, Illinois, Indiana, Michigan, Ohio

    "Nothing is stronger than the heart of a volunteer"

  6. #6
    Join Date
    Apr 2007
    Milwaukee WI

    Default Separate pre-op and post-op?

    You ask: These two are different procedures, so when using modifier 59 with the tonsillectomy shouldn't the insurance pay out the tonsillectomy at 100%?

    No, they shouldn't ... because you won't be doing separate pre and post-op care.

    Remember, the reimbursement for a surgical procedure inlcudes the pre-op visit (day of or day before surgery, unless Decision for surgery), and post op care. If multiple procedures are performed in the same operative session, the multiple surgery discount will apply, because the pre- and post-op care will be handled together.

    F Tessa Bartels, CPC, CPC-E/M

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