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The glorious -59 question!

  1. #1
    Question The glorious -59 question!
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    So I am coding Pain Management. My physician performed a LESI 62311 & SI Inj. 27096, used fluro..... I have gotten feedback from peers that they have been appending -59 to the 27096. In efforts for this thread NOT to get lengthy, I am wondering if someone can help with the definition of -59. I know it is a modifier that can be used to bypass edits. Although there is no edit for (column 1)62311, (column 2)27096 but there is a edit for (column 1)27096,(column 2)62311. If anyone can elaborate on the edits that would be great. But my main concern is why would these two codes warrent the use of -59? Are they not already distinct from each other. I have 2 seperate op reports, they are two seperate site (which isn't it self explainatory for the codes I am reporting?), they have two seperate dx. I am reallly not wanting the "depends on the payer answer" I am wanting a clear definition of when to use -59. Like there is one huh? If coders are using -59 to appended all distinct pocedures, wouldn't that get into the abuse of that modifier and posssible flag an audit? PLEASE HELP!!!!!

  2. #2
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    (These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

    Without knowing the carrier or site of service, I will show you how we are directed to code this in an ASC setting:

    62311-59
    77003-TC
    27096-[location modifier needed]
    77003-59-TC

    Drop the TC (Technical Component) if you are not coding for an ASC. 62311 is the highest paid procedure and should be listed first, but it bundles into 27096 so add the -59 modifier to bypass the NCCI edit. Add the fluoro code for the LESI procedure only if it was fully performed in the Lumbar region (if the LESI procedure had a Sacral component, then code the fluoro only once at the end), then code fluoro for a second time for the SI injection, and add the -59 modifier to indicate that this was in a distinct spinal region.

    Richard Mann, your pain management coder
    rkmcoder@yahoo.com

  3. #3
    Smile
    Thanks so much for your answer! But I have one other question. Since 62311 has a higher RVU and it is listed first, why is there not a edit when you look up that code in the edits?

  4. #4
    Default
    (These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

    I do not know the reasoning behind most of the pain management NCCI edits. Very little was bundled until Q2 (second quarter) of 2009, then all hell broke loose. Look at an LESI and a trigger point. The LESI bundles into the trigger point. This makes no sense at all, yet there it is. CPT Asst tells us to use fluoro code 77002 for many of the injection codes, but NCCI edits bundle the fluoro into the code (look at 64510 and 77002), so even though we are directed to use the code, we must add a -59 modifier to bypass the edits. This only started 01/01/2010. Why? I have no clue!

    So, there are no answers to the mysteries of pain management NCCI edits, or at least I don't know the answers...

    Richard Mann, your pain management coder
    rkmcoder@yahoo.com

  5. Default
    Quote Originally Posted by rkmcoder View Post
    (These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

    Without knowing the carrier or site of service, I will show you how we are directed to code this in an ASC setting:

    62311-59
    77003-TC
    27096-[location modifier needed]
    77003-59-TC

    Drop the TC (Technical Component) if you are not coding for an ASC. 62311 is the highest paid procedure and should be listed first, but it bundles into 27096 so add the -59 modifier to bypass the NCCI edit. Add the fluoro code for the LESI procedure only if it was fully performed in the Lumbar region (if the LESI procedure had a Sacral component, then code the fluoro only once at the end), then code fluoro for a second time for the SI injection, and add the -59 modifier to indicate that this was in a distinct spinal region.

    Richard Mann, your pain management coder
    rkmcoder@yahoo.com
    Thanks for this information but could you clarify the modifier on the 27096, I assume you meant anatomical location?
    Last edited by dav4code; 12-08-2010 at 11:33 AM. Reason: incomplete sentance

  6. #6
    Location
    Denver Colorado
    Posts
    279
    Default
    When these particular CCI edits were created, i.e. most of the epidural and nervous system injection codes (62XXX and 64XXX) were bundled into the vast majority of [U]all other surgical procedure codes[U] based on Standards of Medical / Surgical Practice. Rather than look at each individual surgical CPT code, the nervous system injections codes were bundled "in bulk" into the surgical procedure codes, including some "strange ones like the SI joint and trigger point injection codes, (note both CPT codes are in the musculoskeletal surgical procedure code range.)

    The following is an excerpt from the CCI edit manual -
    [INDENTMany NCCI edits are based on the standards of medical/surgical
    practice. Services that are integral to another service are
    component parts of the more comprehensive service. When integral
    component services have their own HCPCS/CPT codes, NCCI edits
    place the comprehensive service in column one and the component
    service in column two. Since a component service integral to a
    comprehensive service is not separately reportable, the column
    two code is not separately reportable with the column one code. Some services are integral to large numbers of procedures. Other
    services are integral to a more limited number of procedures.
    Examples of services integral to a large number of procedures
    include:
    - Cleansing, shaving and prepping of skin
    - Draping and positioning of patient
    - Insertion of intravenous access for medication administration
    - Insertion of urinary catheter
    - Sedative administration by the physician performing a procedure (see Chapter II, Anesthesia Services)
    - Local, topical or regional anesthesia administered by the physician performing the procedure]...[/INDENT]

    The nervous system injections were considered to potentially be "local, topical or regional anesthesia administered by the physician performing the surgical procedure" which would make the nervous system injection codes to be considered inclusive of the surgical procedure.

    SO, the lumbar epidural is bundled as a column 2 code into the column 1 SI joint injection if it was performed as "local, topical or regional anesthesia" to the SI joint injection and was performed by the physician performing the SI joint injection. As we know in reality, the vast majority of time lumbar ESI are NOT performed as an anesthestic for SI joint injections but rather as a separate and distinct procedure for it's own medically necessary reason. Thus, the potential to report a modifier to bypass the bundling edit is frequent.

    However, you also need to be aware that many payers have "concerns" regarding providers routinely performing multiple pain management procedures during the same session, i.e. lumbar ESI and SI joint injections. Payers typically understand if the patient has a documented medical necessity, i.e. on anti-coagulants, to perform both procedures at the same session but this would more likely be the exception than the rule AND needs to have good documentation!

    Hopefully this helps with the CCI "logic!"

  7. #7
    Default
    62311-59
    77003-TC
    27096-[location modifier needed]
    77003-59-TC

    Listing 77003 twice is CPT guideline for per spinal region, but this not appropriate to bill this way according to the NCCI policy manaul for a Medicare beneficiary.

    http://www.cms.gov/nationalcorrectcodinited/

    3. CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

    __________________________________________________ __________________
    ".......code, we must add a -59 modifier to bypass the edits."


    It also not appropriate to add the 59 modifier to a fluoro code if it is bundled into the procedure code. If you are billing a Medicare patient and you are doing a stellate ganglion block with fluoro , you can not bill 77002 with the 59. You only bill 64510. You have to follow the rules of the 59 modifier, separate site or separate encounter.



    http://www.cms.gov/nationalcorrectcodinited/

    3. CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

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