Coding Corner: Modifier 59 | Sameer Sharma, MD, MBA

Sameer Sharma, MD, MBA

The Correct Coding Initiative (CCI) edits contain pairs of Healthcare Common Procedure Coding System codes (HCPCS i.e., code pairs) that generally should not be billed together by a provider for a beneficiary on the same date of service. All code pairs are arranged in a column 1 and column 2 format. A column 1 code is the primary code or service, and a column 2 code is the secondary code or service and is generally not payable when billed with a code in column 1. Under certain circumstances, a provider may bill for two services in a CCI code pair and include a modifier on the claim that would bypass the edit and allow both services to be paid. A modifier is a two-digit code that further describes the service performed. Thirty-five modifiers can be used to bypass the CCI edits. Modifier 59 is one of these modifiers.

Modifiers XE, XS, XP, and XU are other valid modifiers. These modifiers give greater reporting specificity. Use these modifiers instead of modifier 59 whenever possible. Visit this Centers for Medicare and Medicaid Services (CMS) webpage for more details:

Modifier 59

Each CCI code pair has a modifier indicator that determines whether a modifier can be used. Modifier 59 is used to indicate that a provider performed a distinct procedural service for a beneficiary on the same day as another procedure or service.

1. The Procedure to Procedure (PTP) code pair edits, Medically Unlikely Edits (MUE) tables, and National Council on Compensation Insurance (NCCI) manual are accessed through the National Correct Coding Initiative Edits webpage on the CMS website.
2. Modifier Indicator Table
3. Modifier Indicator Definition
   

Appropriate Uses:

• A different session
• Different procedure or surgery
• Different site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
• Separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
• Second initial injection procedure when protocol requires two separate sites or when the patient has to come back for a separately identifiable service

Inappropriate Uses:

• When another established more descriptive modifier is available and more appropriate
• When used with an Evaluation and management (E/M) service
• If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass)
• To report a separate and distinct E/M service with a non-E/M service performed on the same date (refer Modifier 25)
• When a valid modifier exists to identify the services
• When documentation does not support the separate and distinct status
• When used to indicate multiple administration of injections of the same drug
• When the NCCI tables lists the procedure code pair with a modifier indicator of “0”

Examples:

For most gynecologic oncology cases, Modifier 59 has limited applicability since the procedures are typically being done in the same area using the same incisions. For example, ureterolysis is bundled with hysterectomy codes, and tumor debulking codes (CPT 49203-5). For hysterectomy codes, ureterolysis cannot be added even with Modifier 59. For tumor debulking codes, ureterolysis can potentially be added with Modifier 59, but typically this would not be appropriate since both codes are working in the same anatomical area and through the same incision.

There will, however, be some exceptions to the use of Modifier 59. It can be used to indicate situations in which codes not normally reported together are being submitted because of special circumstances. For example, if an ovarian cystectomy is performed at the time of a supracervical hysterectomy due to a suspicious lesion on the ovary, the code and payment are unchanged regardless of whether tubes and ovaries are removed or left in place. In cases in where the uterus, tubes, and ovaries are removed, lesser procedures, such as an ovarian cystectomy, generally are not reported separately. In this case, however, only the uterus was removed. The ovarian cystectomy is reported as an additional service since it was not integral to the hysterectomy. Modifier 59 is used to indicate the atypical circumstances.

The use of Modifier 59 helps to clearly specify situations in which a service is distinct and separate from others performed on the same day. It should not be used simply to express disagreement with the CCI, but rather as a way to indicate special circumstances of the case.

Sameer Sharma, MD, MBA, is a gynecologic oncologist at Northwest Cancer Center in Dyer, IN.

Join the SGO Coding and Reimbursement Subcommittee for the Annual Coding Course on Friday, March 15, 2024 from 1-4 p.m. during the SGO Annual Meeting on Women’s Cancer in San Diego, CA. Delve into the process of creating CPT® codes, spanning surgical and E/M services. Navigate coding for diverse cases in ovarian, cervical, vaginal, and endometrial cancer, including pre-op consults, surgery, advanced care planning, and chemotherapy, enhancing your coding proficiency in a range of patient care scenarios. In these case-based lectures, we will go through scenarios both common and complex, walking you through the billing of visits and surgery cases from start to finish. Presenters will also discuss new codes recently approved by the AMA RVS Update Committee (RUC) and how they can be utilized. Participants will be eligible for 3 CEUs upon completion.