Modifier Moment-59

Modifier Moment-59

The 59 modifier is one of the most misused. I believe it lies in the fact that many coders rely on Encoders but do not apply the known coding guidelines to the information given. 

For example we are told when we place 2 codes in an Encoder “ a modifier MAY be used to override this edit” . But DOES NOT mean that 59 applies. 

As Mom always said “just because you can does not mean you should”. Sometimes we can do things that are just plain wrong!  
Do not let an Encoder tempt you to add a modifier when the applicable guideline does not allow. Be VERY VERY careful when you see the advice “ a modifier May be used… “ ALWAYS ask yourself, does the document I am coding meet the necessary requirements based on the guidelines I need to apply?

What are the requirements? You need to look up the definition of modifier 59 
What is CPT code modifier 59?

“The full definition of modifier 59, again from the AMA’s CPT 2012, is:”Distinct Procedural Service: 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”

I cannot tell you how often I see this on an EM code. This is non-EM modifier, by definition. 

Still confusion exists over what is distinct and independent. This is where you must find support in the applicable guidelines. 

CPT/AMA allows us for example to separate the shoulder into anterior, posterior and subacromial space. But CMS tells us the shoulder as a whole is a single anatomical site?

Still confused? I’ll bet. Clear as mud! You must be using the correct support to code and defend your documentation because we have CPT then we have more restrictive CMS guidelines, which do we follow? To make matters worse some payers have their own payer guidelines.You always follow at minimum CPT/AMA, for government payers you’ll follow CMS/NCCI and for commercial payers you need to know if they use NCCI or not or if they have their own list of code edits.

All government payers follow the more restrictive CMS guidelines but many commercial are not as restrictive. This could potentially mean you are able to use modifier 59 in a shoulder case on a commercial patient while a MCR patient with the same services documented you could NOT unbundle the component code even if in different area of the shoulder due to their restriction of the shoulder being one anatomical site.

The knee remember is  divided into medial, lateral and patellofemoral compartments. You need to carefully read your CPT book and code descriptions – as you can see 29881 includes “debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed” , since CPT covers all entities we can never code a separate chondroplasty in the same knee.

Do not simplify these things to be paid, your providers can get in serious trouble if you have even unintentionally unbundled services and received payment.

Our job as professionals is to capture the correct revenue by applying correct coding principles. If you have guidance in writing by CPT/AMA primarily, NCCI or payer specific secondarily you and your provider will not ever be concerned about future take-backs or fines due to coding errors. 

59 is NEVER to be applied just because you can, you must first KNOW that you SHOULD. 

Marie Popkin, CPC
Coding,Consulting & Compliance