One of the most frequent errors can result from using the wrong modifiers. In addition to the accurate coding of treatment, medical claims must be billed in combination with codes for additional services performed in the office, the corresponding modifiers, if necessary, and ICD-10 or diagnosis codes. In this article, we will be discussing wrong modifier combinations for modifier 59 (Distinct procedural service).
The 59 modifier is one of the most misused modifiers. The most common reason it should be used is to indicate that two or more procedures were performed at the same visit but to different sites on the body. Unfortunately, many times it is used to prevent a service from being bundled or added in with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.
Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.
If Modifier 76 is included in the medical claim, then it is considered invalid if used with Modifier 59. Modifier 59 refers to procedures or services completed on the same day that is because of special circumstances and are not normally performed together. Modifier 76 refers specifically to the same procedure performed multiple times by the same medical professional after the initial service.
Modifier 59 is added to a procedure to distinguish a procedure as a different session, different surgery, different procedure, different site, different organ, separate incision, separate excision, or separate injury from the previously reported procedure that was performed on the same day by the same physician.
Avoid Indiscriminate Modifier 59 Use
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote correct coding and prevent improper payments. The edits are updated quarterly. Unfortunately, modifier 59 is often used incorrectly to bypass NCCI edits. Examples of such inappropriate use include:
- Appending modifier 59 to a diagnostic procedure performed prior to a scheduled therapeutic procedure, when the basis for the diagnostic procedure did not lead to the decision for the therapeutic procedure
- Appending modifier 59 to a diagnostic procedure performed following a therapeutic procedure, when the diagnostic procedure is considered a component of the therapeutic procedure
- Appending modifier 59 to a claim just because the service was denied as a bundled service
The biller should never be the one to add the 59 modifiers to a claim, even if she knows that billing the services without the modifier will result in bundling or a denial. The 59 modifiers should only be added by the provider or by a coder who has access to the patient’s chart.
If you are the biller and you believe that the 59 modifiers would be appropriate but was not indicated, you should go back to the provider to see if it was omitted by mistake. Don’t just add the modifier to the claim without substantial evidence that it is needed.
- A different diagnosis is not needed to append modifier 59.
- A different diagnosis doesn’t automatically qualify a code for modifier 59 if the above criteria have not been met.
- Modifier 59 should never be used to simply bypass an edit when the above criteria have not been met.
- Modifier 59 is appended to the Column 2 code in the NCCI table.
- Modifier 59 is not an evaluation and management modifier.
- Make sure your physician documents everything clearly. For example, “A separate incision was made,” “A different modality was used to remove the polyp,” “Patient was brought back to the operating room,” etc.
- Read the documentation. Do not append modifier 59 simply because your software’s edit states to add modifier 59.
There are a lot of wrong modifiers like 24, 25, or 50 which are used wrongly or used with wrong combinations. We will be discussing those in our upcoming articles. Many of these coding mistakes can be avoided if you have properly trained medical coding personnel. Another easy way is you can get connected with Medical Billers and Coders (MBC) who have such experts. Our coders are constantly trained to stay on top of medical coding. To know more about our medical billing and coding services you can call us at 888-357-3226 or write to us at firstname.lastname@example.org