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modifier 59

  1. Default modifier 59
    Medical Coding Books
    I billled 45385 and 43239 together to Care Improvement Plus. They reviewed the charge and state that it was billed incorrected due to no modifier. The letter they sent suggested putting a 59 on the 43239. Since these are different anatomic sites I saw no reason to append the 59. What should I do?

  2. #2
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    Try a 51 modifier-mutliple procedures

  3. Default
    They are correct. A 59 modifier would be used if there are two different anatomic sites. A 51 modifier would be used if multiple procedures are used in one anatomic sites. The 51 modifier allows for reduction of the second procedure.

  4. #4
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    Quote Originally Posted by simonewill7 View Post
    They are correct. A 59 modifier would be used if there are two different anatomic sites. A 51 modifier would be used if multiple procedures are used in one anatomic sites. The 51 modifier allows for reduction of the second procedure.
    That is not correct on the definition and use of the modifiers. These two codes need no modifier to make them distinct from each other (59) as by descriptor and definition they are already as distinct as they need to be, however some payers still want you to indicate that the two procedures were accomplished in the same setting(51).
    The 59 modifier is use to distinguish when two procedures are distinct and separate from one another when they would otherwise be bundled together.
    The 51 tells the payer that the second and subsequent procedures were performed in the same procedural session for multiple procedure discounting.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Debra, in your hurry to say that I am incorrect, you only repeated what I said. Maybe you did not understand fully my description of it. I repeat, the insurance carrier is correct that a 59 modifier would need to be added according to correct coding guidelines along with CMS's guidelines on proper usage of the 59 modifier. I have been auditing for many years, this has never changed, it only confuses many coders. Either the insurance carrier, CMS, and Encoder Pro are wrong, or you stand corrected.
    Last edited by GaPeach77; 12-30-2011 at 10:22 AM.

  6. #6
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    for this combination you do not need the 59 to indicate distinct and separate as the code descri0tor already states this. If the carrier is wanting a modifier it could only be the 51 to indicate multiple procedures in the same procedural session. This is not what you stated.

    Addendum:
    There is no CCI edit for these two codes
    Last edited by mitchellde; 12-30-2011 at 11:12 AM.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    Debra,
    That is incorrect. The endoscopy and colonscopy are two different organs and two different anatomical sites. As I mentioned earlier, a 59 modifier would be the correct modifier according to coding guidelines.
    Why would you use a 51 modifier and get a reduced pricing rate when the carrier is stating that they will pay both procedures at 100% if you use the 59 instead? It may be beneficial to you to do a little research on your own about the difference between distinct and mulitple procedures, you appear to be a little confused on this issue.

    ENCODER PRO: DEFINITION OF 59 MODIFIER

    "Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25"
    Last edited by GaPeach77; 12-30-2011 at 11:23 AM.

  8. #8
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    Quote Originally Posted by simonewill7 View Post
    Debra,
    That is incorrect. The endoscopy and colonscopy are two different organs and two different anatomical sites. As I mentioned earlier, a 59 modifier would be the correct modifier according to coding guidelines.
    Why would you use a 51 modifier and get a reduced pricing rate when the carrier is stating that they will pay both procedures at 100% if you use the 59 instead? It may be beneficial to you to do a little research on your own about the difference between distinct and mulitple procedures, you appear to be a little confused on this issue.

    ENCODER PRO: DEFINITION OF 59 MODIFIER

    "Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25"
    I understand the definition of the 59, it will not make the procedures pay at 100%. It is not needed for this paring as these two procedure are normally performed together and need no separation as they are already descriptive for separate organ. They are normally performed in the same session and that is why the 51 modifier is still wanted by some payers.
    Your earlier definition of the 59 and 51 is still incorrect, you do not use the 59 to indicate different organ and the 51 to indicate multiple sites of the same organ. That is what I was correcting
    Also there is no need for a modifier with this pair beyond the 51.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default
    Debra,

    A 51 is used for as it's stated-multiple surgeries. The two codes in question are -oscopies not surgeries. The endoscopy and colonoscopy are considered procedures per use of correct modifier application. As I posted, the use of 59 by anatomical site is not my definition but the definition of Encoder Pro. I don't know what your definition of distinct procedural service is because you have not define one, I will stick with coding guidelines and Encoder Pro's definition of a distinct service as stated in my last post. I could hardly drop that and pick up your interpretation or definition when you have failed to state one. Also, the 51 modifier does reflect the multiple surgery pricing reduction with most payers. Let me add, that if you use the 59 modifier and a payer does not reimburse at 100% of the contracted rate, then that decision should be appealed.
    Last edited by GaPeach77; 12-30-2011 at 12:43 PM.

  10. Default Wow, what a good debate! But I still don't know what to do.
    I went to the Nashville Regional Conference and the speaker from Yale agrees that no modifier is needed because the description itself is sufficient. The difference may be that one of you debating may be a hospital coder and the other from a physician's office. If I put a 59 on the EGD that means I'm asking for full payment. So they probably owe me money! But after a phone call from Care improvement plus they said just to do what the leter says. I am going to send it with a letter of why I still disagree with them. Coding is never easy! Thanks for your input. Much appreciated

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