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Modifier -59 in Cardiology

  1. #1
    Question Modifier -59 in Cardiology
    Medical Coding Books
    Our office utilizes the -59 modifier quite often. I wanted to make sure that we are doing this appropriately as I know that it puts us at risk for audits.

    I wanted to know if it is OK to append a -59 modifier for these particular scenarios:

    1. 93015 bundled into 99204
    2. 93000 bundled into 93015
    3. 78452-26 bundled into 99217
    4. 93306-26 bundled into 99217

    We typically submit a claim for denial and once the claim is denied, we appeal by appending the -59 modifier and supporting medical records.

    Is this an appropriate way to handle this or should we just append the modifier without the notes being sent or are we just not doing this correctly?

  2. #2
    Columbia, MO
    It just depends on if in fact you can unbundle the services If documentation does support the unbundling then apply the modifier up front for initial submission. You do not need to wait for a denial when you have the modifier and the supporting documentation.

    Debra A. Mitchell, MSPH, CPC-H

  3. Cool
    If the documentation supports both services being billed then the modifier should be added at the initial submission. there is no reason to wait for a denial.

    Make sure that you have sufficient documentation to support the "unbundle"
    Especially on that ekg and stress test. If the ekg is run at the beginning of the stress test (same leads) then you would not bill the ekg. Using the 59 modifier on 93000 says it is distinct (separate). A baseline ekg is part of the stress test. Be careful with this one

    Most common usage in a Cardiology office is
    Stress test and office visit on same day
    EKG, Device check and office visit on same day
    Hospital care on same day as a procedure (25 modifier)
    two distinct procedures on same day
    to name a few

  4. #4
    Hartford, CT
    1) Modifier 59 on 93015 is not appropriate, if the documentation supports it you should be adding a 25 modifier to 99204.
    2) Yes if documentation supports
    3 & 4) According to CCI these are not bundled so you should not need any modifiers, if the insurance other than medicare you should probably check any restrictions in your ocntract or the patients' policies

    Doreen, CPC, CPMA

  5. #5
    @ bsanzone - we do not use the same leads to stress a patient that we used to do an EKG but we do perform a baseline EKG at the start of an ETT. Would that still constitute the use of -59 modifier? I was always under the assumption that if the patient came in complaining of Chest Pain and we perform an EKG and that EKG is abnormal, we would bill the EKG with -59 MOD and ICD9 Chest Pain and ETT with Abnormal EKG, the -59 modifier was used to state that patient had an EKG for a different diagnosis.

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