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modifier 59 fee reduction

  1. #1
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    Greeley, Colorado
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    Question modifier 59 fee reduction
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    If modifier 59 is used appropriately (ie different procedures different site) is there a fee reduction? I was taught many years ago that there wasn't. If anyone knows where I can find information on this I would be extremely grateful.
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Location
    Columbia, MO
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    Default
    The 59 modifier allows for reduction because each procedure contains the reimbursement for the prep as well as the procedure. The 59 says this procedure is performed in the same session, there for the prep is then carved out of the reimbursement or as we say discounted.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Greeley, Colorado
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    Thanks Debra.
    Lisa Bledsoe, CPC, CPMA

  4. Default Modifier 59
    I may be misunderstanding the above answer. A Modifier 59 attached to a procedure code indicates that it is a separate procedure and is NOT subject to the multiple surgical reduction; as a result, it should be paid at 100% of the fee schedule.

    I am not aware of any contracts that use a graduated reduction scale when a modifier 59 is used. As a matter of fact, BCBS recently signed a settlement agreement with the AMA agreeing NOT to reduce procedures that had a modifier 59 attached.

    Some systems are set up to automatically ignore the modifier 59 and in those cases, you should appeal

    Melanie

  5. #5
    Location
    Columbia, MO
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    The 59 modifier indicates a distinct and separate procedure that is not subject to BUNDLEING but is subject to discounting. Most payers will discount when more than one procedure is performed in the same session. If you can have a contract that states otherwise then great. But the 59 is not what will stop discounting it does however stop bundleing unless it is a non modifiable pairing.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Location
    Milwaukee WI
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    4,466
    Default Reduction for multiple surgery
    It would still be appropriate to have a multiple surgery reduction on the second, third, etc surgery performed in the same operative session.

    The reimbursement for all surgical procedures includes pre- and post-operative care.

    Just because you perform two procedures in one session does not mean you will have the patient come in for two distinct postoperative visits.

    Basically the -59 tells the payer that this was a distinct procedure and should not be bundled into the primary procedure. The multiple surgery discount will still apply because you will NOT have a distinct postoperative period for the second and subsequent surgery(ies).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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