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Modifer 59 in Urology ?

  1. #1
    Question Modifer 59 in Urology ?
    Medical Coding Books
    I have a Urologist asking if he can bill the same procedure twice with modifer -59 when he removes more than one calculus during the same session. I am thinking no but I want to be sure.

  2. Default
    It would be best if you would be specific about exactly what procedure he is performing and the anatomic locations of the stones, but the answer will almost certainly be that he cannot do this. The definition of modifier 59 through the AUA's coding website states:

    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.

    This would prohibit him from using 59 in cases when he is doung a u-scope to basket/laser two stones, or when removing more than one stone from the bladder.

  3. #3
    Austin, Texas
    Look at modifier 22 if extra time is required beyond the usual time for this procedure.
    Marcus Murphy, CPPM

  4. Exclamation is 22 appropriate?
    I would caution against using the 22 modifier for a couple reasons. The first is that it will automatically trigger a manual review, and you will need to send medical records with your 2nd claim when requested. This additional work can take time, and delay payment of your claim for a relatively small procedure.

    Also, by definition modifier 22 states "When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required)."
    I would not say that simply removing another calculus is substantially extra work, makes the procedure more difficult or greatly increases time, technical difficulty of physical and mental effort.

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