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Modifier 59 Conundrum

  1. Talking Modifier 59 Conundrum
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    Morning All..

    I had a rather interesting discussion with not one, but two CSR's at Palmetto GBA, Ohio Part B Carrier. One of my staff was advised to append modifier 59 to one of our Fluoroscopy codes (77003) as it was bundled into the procedure performed. Of course she obliged...and rebilled the claim with the 59 modifier. I explained to her that she cannot do this because the Fluoro is required to perform the procedure, and it is not separate. She then told me she was advised this way by Medicare.

    Okay...so I called them myself and spoke with TWO different CSR's (Crystal & Katoya)there who told me I COULD append the 59 modifier to the Fluoro because it was a separate procedure...??????...hmmmm....this is not how I understood the -59 modifier. I also directed THEM to THEIR Modifier 59 article and gave reference to "Surgery: Example 6"... and read them both, verbatim: "Cpt modifier 59 is only appropriate if the ultrasonic guidance is performed for a procedure that is UNRELATED to the surgical laparoscopic ablation procedure..." STILL, after reading this to them, I was told that I could append the -59 modifier because (again) it was a separate procedure!! OMG....so wonder Medicare is so messed up, and now I am confused as I though I understood it.

    Any thoughts out there on this one??? Thanks for setting my mind straight, as I think I have lost it....

  2. #2
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    Yikes.
    Is this their (CMS) way of giving it now....and penalizing later?

  3. #3
    Location
    North Carolina
    Posts
    3,126
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    Quote Originally Posted by Dan View Post
    Yikes.
    Is this their (CMS) way of giving it now....and penalizing later?
    Couldn't have said it better...


    I've had a similar experience but with Medicaid. Some time back, a Medicaid rep instructed one of our billers to append mod 59 to the lidocaine code (J2001) in order to receive reimbursement. For whatever reason, J2001 was being billed with 20610. Needless to say, quick intervention took place and education was provided to the Medicaid rep & employee that 1) Lidocaine is bundled into this service 2) J2001=IV infusion.

    Too bad we can't bill the carriers for our educational services...

  4. Thumbs up
    Quote Originally Posted by rebeccawoodward View Post
    Couldn't have said it better...


    Too bad we can't bill the carriers for our educational services...
    Oh I agree....they should be paying us the BIG BUCKS!!

    ....and I wonder why some days I leave here with a headache!!

  5. #5
    Location
    Sioux Falls South Dakota
    Posts
    358
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    I had a similar problem with Medica. Young lady is admitted to deliver; she also has a hematological problem, so OB/Gyn calls in hematologist to see her. He charges a visit (not a consult, as she was his patient, he didn't feel it met criteria for consult, etc.) - I think 99232. Medica denies as part of the global OB package. Follow up person appeals, stating different specialty; they deny again because same Tax ID. I called them and was told if I just append modifier 24 it would pay - by a supervisor! Needless to say, we did so.
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  6. Default
    We have a similar case in that our doctor does procedure code 19296 insertion of a balloon cathether and in the past used 76942 (ultrassound guidance) along with the code. Edits as of 2005 say this bundles but can be unbundled with appropriate modifier. Our insurance clerk has been adding mod 59 to this and getting the procedure paid. Myself along with the other coder in our office do not feel that this is appropriate but our collection clerk (who recently received her CPC) has advised the insurance clerk that it is okay to do this. In fact her point of argument is that even if the mod is not correct we should use it to get the claim past edits and then the insurance company will determine whether it will be paid or denied. Has anyone ever heard of just using a mod to get past edits........ I mean that to me is improper coding and should send up red flags everywhere for an audit!!!!!

    Pebbles

  7. #7
    Location
    Columbia, MO
    Posts
    12,557
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    Quote Originally Posted by Pebbles1218 View Post
    We have a similar case in that our doctor does procedure code 19296 insertion of a balloon cathether and in the past used 76942 (ultrassound guidance) along with the code. Edits as of 2005 say this bundles but can be unbundled with appropriate modifier. Our insurance clerk has been adding mod 59 to this and getting the procedure paid. Myself along with the other coder in our office do not feel that this is appropriate but our collection clerk (who recently received her CPC) has advised the insurance clerk that it is okay to do this. In fact her point of argument is that even if the mod is not correct we should use it to get the claim past edits and then the insurance company will determine whether it will be paid or denied. Has anyone ever heard of just using a mod to get past edits........ I mean that to me is improper coding and should send up red flags everywhere for an audit!!!!!

    Pebbles
    WOW! and I cannot say that loud enough!! You never put on a modifier just to slip past the edits, if this were true then there is no rationale to have the edits in the first place. There is somewhere in the regulations that payers are not allowed to tell us how to bill a claim and if they do and we take their advice is is not a defensible position that we did it because x individual told us we could. Knowledge of the rules and regs is our responsibility when it ocmes to coding of the claims. A payer can inform us of policy issues but cannot instruct on specific coding aspects such as "use this modifier"

    Debra A. Mitchell, MSPH, CPC-H

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