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Modifier 59 Usage

  1. Question Modifier 59 Usage
    Clearnace Sale
    I recently passed my CPC-H exam and don't have the required experience so am an apprentice for the time being. Right now I work as a biller in a local hospital. I had a claim with several CPT codes with modifier 59 and one with modifier 79. I work at a Critical Access Hospital so pro fees are on the claim along with the facility fees. This particular claim was bill type 851. I don't believe the modifiers are being used correctly so I posed my questions to my supervisor who checked with HIM and the person who coded the account. I was told it was correct and to send the claim. I did but I still don't think it is correct. I don't think the modifiers are being used correctly. The CPT codes on the claim were as follows: 96360-59; 96361; 88304; 47562; 44005-59; 94664; 94667-59; 94668; 96372-59; 96375-59; and 47562-79. The patient was in observation for 17 hours. I don't think -79 is correct at all nor do I think -59 is correct on 44005. Can anyone help clarify for me why this claim is correct? Thanks!

  2. #2
    Columbia, MO
    From the face of things it looks way wrong to me. First of all whay a 59 on the hydration code ? why a code for additional IVPush?, why a 79 modifier for unrelated on the same code? why a 59 on the enterolysis? why a 59 on the injection code? I have too many questions , if I had more documentation and the rev codes for each line item it would really help.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I thought it was wrong but am just an apprentice so . . . . The rev codes are 260 for 96360-59 and 96361; 310 for 88304; 360 for 47562 and 44005-59; 410 for 94664, 94667-59, and 94668; 940 for 96372-59; 960 for 47562-79 and 96375-59. Should there be a modifier for the IV's? Aren't they part of the procedure? And I didn't think a 59 modifier was allowed with the code pair of 47562 and 44005. And the 79 modifier for the pro fee for the procedure makes no sense.

  4. #4
    Columbia, MO
    Ok I see a little better now. The 44005 is not going to work even with a 59 unless there is documentation of a separate incision. Plus your procedure codes must match the physician. The hydartion will not work unless there is docuemtnation of dehydration, put another way unless there is therapeutic value to the patient outside of the procedure then it is part of the procedure. so I am assuming then the 96360 and the 96361 go away, and honetly even if not they do not require a 59 mod. I have no idea why a 96375 but if supported by doc you would not use a 59. Same with the 96372 it needs no 59. so IF supported by doc then
    360 - 47562
    360 - 44005 (no 59 uless separate incision)
    410 - 94664
    410 - 94667
    410 - 94668
    260 - 96360
    260 - 96361
    260 - 96375
    940 - 96372
    310 - 88304
    960 - 47562
    960 - 44005 (you must charge same procedure as the facility or not for both)
    you do not charge the 96375 for the physician that is a facility code when performed in the facility.
    I see no need for any modifiers here. the rev code will delineate the physician charges.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Thank you! I didn't think there should be a -59 on there let alone the -79. For some reason they seem to want to slap a modifier on everything and it is mostly a -59. I think it is way overused but then again, I am not an experienced coder just an apprentice.

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