Modifier 59 - Friend and Foe

July 16th, 2012

While reviewing an inappropriate denial for two codes as "bundled," I went to the source...CMS.gov's own CCI information for documentation.

Much to my wandering eyes' amazement, I noticed an article on Modifier 59.  It was the ONLY article on any modifier on the page.  Hmmm?

Coders know, Modfier 59 is a wonderful way to help get a claim paid.  CPT® Guidelines tell us that the modifiershould be used if a procedure or service was distinct or independent from other services performed on the same day. 

This could mean

  1. a different session or patient encounter,
  2. a different procedure or surgery,
  3. a different site or organ system,
  4. or a separate incision/excision.

If one of the four is true, two codes that were once "bundled," may be unbundled.  Both will be paid with the addition of modifier 59.

Unfortunately, many practices' AR staffs are so concerned with getting in every dollar that they add modifer 59 WHETHER OR NOT one the four criteria above has been met.   Although this will mean extra dollars in your pocket, if used too frequently you may be cherry picked as an outlier for a Medicare audit.

As the ONLY modifier specifically discussed on Medicare's CCI page, this is clearly of concern! 

You may read CMS's article yourself at:

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

Tags: Modifier 59, CCI (Correct Coding Initiative)

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