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Modifier 51 or 59??

  1. #1
    Cool Modifier 51 or 59??
    Medical Coding Books
    Hello!!

    I have a case with several excision procedures and i do not know which modifiers to use... the dx is 216.5 (4 on the back and 3 on the chest).

    11404
    11403
    11403
    11402
    11401
    11401
    11401

    I need you help! Thanks!!

  2. #2
    Location
    Columbia, MO
    Posts
    12,843
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    11404
    11403 59
    11403 59
    11402 59
    11401 59
    11401 59
    11401 59
    The 59 will keep the smaller ones from bundleing with the larger and also will keep the same code numbers from denying as duplicates. Depends on the carrier for the 51 but if you do use it, it will go after each 59.
    The 59 indicates each procedure is a distinct and separate procedure and the 51 says these were all excised in the same session.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Thanks a lot Debra! That really helped me out

  4. #4
    Default
    According to my Derm coder it should be billed as follows. Keep in mind that it also depends on the payor. The derm coding software we use is based on the Medicare cci edits.

    11404
    11403
    11403-76
    11402
    11401
    11401-76
    11401-76

    None of these excisions are bundled into each other but you have to place the 76 on the repeat procedures so that they do not deny as duplicate. 59 will also get them threw the edits but you might get denials as duplicate charge entry.

    Hope that helped
    Luz Cruz-Johnson CPC,CPCD,PCA

  5. #5
    Location
    Columbia, MO
    Posts
    12,843
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    the 76 is inappropriate. The 76 is for a repeat procedure, when you do an excision on a different area then you have not repeated the same procedure you have performed a different a distinct procedure hence the 59. I hate to disagree with your software. The 59 will get the code thru the duplicate code edit. a repeated procedure must be the exact same procedure repeated at a different setting. when you excise a different lesion then it is not the exact same procedure. An example of a repeated procedure would be a post reduction xray. or a repeated nebulizer.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Default
    Debra thats exactly what i use to think. I attended a dermatology seminar by Inga Ellzey who is a very well know dermatology guru and she explained to use the 76. When I took the CPCD course and exam they said that the appropriate modifier is 76. I have been using this ever since and it has been working just fine. I do agree with 59 being more appropriate but according to the "rules" they state to use 76. LIke i said prior to I was using 59 also, and in some cases getting that duplicate denial from some payors and ultimatley having to submit documentation and path reports.

    Luz Cruz-Johnson CPC,CPCD,PCA
    Last edited by LCRUZ515; 03-31-2010 at 09:58 AM.

  7. #7
    Location
    Columbia, MO
    Posts
    12,843
    Default
    I hear you but I really still disagree. The 76 modifier by definition indicates this procedure was repeated at a different setting. In this way it bypasses discounting. This is a bad thing when in fact the procedures all took place in the same session. I still say it is the 59. I understand you have heard otherwise from those who are well regarded in the industry. But I respectfull disagree.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Location
    Toms River, NJ
    Posts
    51
    Default
    I attended a seminar by Inga Ellzey as well this past January and she also taught us to use modifier 76 however she did state that it depends on the carrier. She is located in Florida and perhaps the carriers prefer modifier 76 however I do agree with Debra that modifier 59 is correct and NJ Medicare has no problem with it. Neither do the commercial insurances we bill.

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