I have several practices that insist on appending the 59 modifier to every procedure, drug, etc, when billed on the same day as an E/M, or if more than one procedure is done. For example: 99213-25, 82947-QW59, 20600-59, 69210-59LT, J1100-59 Or 11401-59, 11420-59. Any advice on how to get through to them that these are being misused and are unnecessary.
If the claims are being denied or paid at a lower rate, I would think that would get through to them.
Originally Posted by cheermom68
Modifier 59 is used only when:
1) you know for a fact that a claims processing edit exists that will deny a lesser code based on an assumption that this lesser code is already being paid for within a more comprehensive code reported on the same claim, or is mutually exclusive to another code (they can't normally both be done at the same time).
2) you know for a fact that the assumption is invalid in this unique case because of the two codes representing services performed at distinct anatomic sites or at different sessions.
What follows are quotes from Medicare's NCCI manual:
The CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together.
There are several general principles that can be applied to the edits as follows:
1. The component service is an accepted standard of care when performing the comprehensive service.
2. The component service is usually necessary to complete the comprehensive service.
3. The component service is not a separately distinguishable procedure when performed with the comprehensive service.
Each NCCI edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances. A modifier indicator of “9” indicates that the edit has been deleted, and the modifier indicator is not relevant.
The existence of the [“1”] NCCI edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations.
It is very important that NCCI-associated modifiers [such as “59”] only be used when appropriate.
Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.
NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers [indicator “1”], the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters. Carrier (A/B MAC processing practitioner service claims) processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met.
Modifier 59: Modifier 59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures [where an edit exists that identifies the fact that one is usually performed as a component of the other] are [in this particular case] performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.
Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
Seth Canterbury, CPC, ACS-EM
Thanks for the great info.
Which of the following is an acceptable indication to use modifier 59 to bypass an NCCI edit
I would also let the office know that insurance companies keep track of the use of modifier 59 and by using the modifier inappropriately they are setting themselves up for an audit. In an audit they will find something incorrect and they will owe money back to the insurance company. Audits can be very costly and very time consuming. The insurance company will assume that if they are using the modifier 59 as a rule which is not how it should be used that they are certainly doing other things wrong.
I would print out NCCI edits in case someone gonna want to see something in writing. I have never seen -59 appended on J codes.
Originally Posted by cheermom68
NCCI edits: https://www.cms.gov/nationalcorrectcodinited/