Health Information Management

Use modifier -59 sparingly when reporting add-on codes

JustCoding News: Outpatient, July 14, 2010

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One of the reasons that both new and experienced coders incorrectly append modifier -59 is because several common myths and misconceptions persist, which contribute to risky coding habits. One such habit is appending modifier -59 to add-on codes without discretion.

“The intention for the use of modifiers by the [American Medical Association] is not to append them unless they’re necessary by policy to identify either a different site or a different location or lesion,” said Peggy S. Blue, MPH, CPC, CCS-P, regulatory specialist at HCPro, Inc., in Marblehead, MA, and lead instructor for HCPro’s Medicare Boot Camp®-Physician Services and an instructor for the Certified Coder Boot Camp®. “Generally speaking, we do not need to report modifier -59 on add-on codes.”

Add-on codes (listed in Appendix D of the 2010 CPT® Manual) enable physicians to separately identify a service that they perform as an additional service or a commonly performed supplemental service that is related to the primary procedure, said Blue during HCPro’s May 18 audio conference “Modifier -59 Myths Busted: A Case Study Approach to Correct Use.”

“On the surface, modifier -59 seems like a great solution to get some denied codes paid. Unfortunately, that little magic modifier which seems so great can turn against you if it’s not properly used,” Blue said. “Improper use of modifier -59 can be considered abusive or it can even be considered fraudulent billing.”

Modifier is often inappropriate when reporting add-on codes

For example, when a physician performs a hysterectomy following a cesarean delivery, you may report the appropriate code for the delivery along with add-on code +59525 for the hysterectomy. A modifier is not necessary in this case, Blue said.

To further illustrate the use of modifier -59 with add-on codes, consider procedure documentation for two lumbar (right side) transforaminal epidural steroid injections; the first injection applies to L2-L3 and the second injection to L3-L4. So this indicates injections for two interspaces.

For this procedure, you would report code 64483-RT and add-on code +64484-RT.

“That is all that is required to let the payer know that there’s an additional level,” said Susan E. Garrison, CHCA, CHC, CCS-P, CPC, CPC-H, PCS, FCS, CPAR, executive vice president of Healthcare Consulting Services at Magnus Confidential, Inc., in Dawsonville, GA. “Add-on procedures rarely would need a modifier to bypass bundling edits.”

Modifier may apply when bundled codes are appropriate

However, let’s look at a different aspect of an add-on code scenario.

Consider CPT code 26123 for a fasciectomy, partial palmar with release of a single digit for one finger. Also note add-on code +26125 for each additional digit.

Codes 26123 and +26125 don’t need a modifier because they don’t bundle together, said Garrison, who also spoke during the audio conference.

However, code 26123 does have the following services bundled with it:

  • 20526: carpal tunnel injection
  • 25259: manipulation of the wrist while patient is under anesthesia

“There are some potential times when an add-on code may or may not need a modifier -59 or another service that’s being billed in addition to an add-on code might need a modifier -59,” Garrison said. “You still need to look to see if there are bundling edits included in these particular services.”

The following four codes bundle into add-on code +26125:

  • 20526
  • 25259
  • 26340: manipulation of the finger joint while patient is under anesthesia
  • 29086: cast application for the finger

“If any of those codes are appropriately billed in addition to code +26125 because they are performed on separate fingers, you would need a modifier, possibly -59 or other appropriate modifier, on that additional code,” Garrison said.

Also, code 11010 for debridement with open fracture and/or dislocation is mutually exclusive to add-on code +26125.

“There are some scenarios where even if you have an add-on code, there might be bundling issues that play a part of that, and you need to take a look and see what bundles into which one, and whether or not you would need a modifier on one code or the other to appropriately bypass it,” Garrison said. “But generally, add-on codes don’t need a modifier to bypass a bundling edit as long as they’re billed in addition to the primary code.”

Editor’s note: E-mail questions to Managing Editor Doreen Bentley, CPC-A, at dbentley@hcpro.comFor more tips and suggestions for correct use of modifier -59, purchase a copy of HCPro’s May 18 audio conference “Modifier -59 Myths Busted: A Case Study Approach to Correct Use.” 

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