Health Information Management

Q&A: Disagreement over modifier -59 usage

APCs Insider, October 17, 2014

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Q: We have a debate going on at our facility. We have a new cardiologist who orders an EKG before and after all his heart catheterization procedures and stress tests. He insists that we should be adding modifier -59 (distinct procedural service) to each of these because they are not done as part of the procedure. Our compliance office disagrees. Is it appropriate to add modifier -59 in this scenario?
 
A: In order to determine when to use modifier -59, the first question should always be, “Is there a more appropriate modifier that can be appended to explain the situation?” In this situation, the answer would be no, as none of the anatomical modifiers or other modifiers—such as those for a repeat procedure—are applicable.
 
The next questions to ask—based on the documentation for the particular encounter—revolve around the purpose of the EKG being ordered. Is the EKG related to the catheterization procedure or stress test in any way? Why is it being done? Does the documentation state that the patient was having signs/symptoms of some complication or adverse event?
 
If the physician ordered the EKGs as part of the order set before performing the cardiac procedure, the purpose is usually for a baseline before the procedure and to check to be sure that the patient returns to baseline after the procedure. From a clinical perspective, this is an acceptable practice.
 
However, the big questions are:
  • Can the procedure be reported with a CPT® code?
  • Does the documented medical necessity support reporting the procedure?
 
When a physician orders a cardiac procedure, typically there has been consideration or indications that there is a cardiac situation that needs to be evaluated. In these cases, when the physician orders the EKG as part of the order set for the procedure, the EKGs are part of the procedure. No sign/symptom of a problem supports the medical necessity of reporting the procedure. The EKG can be done, but should be reported as part of the cardiac procedure.
 
If, however, the patient has signs/symptoms of some issue occurring, such as chest pain after the cardiac procedure is over and wants to leave the facility, then test has a diagnostic purpose. The physician needs to know what the patient’s cardiac rhythm is to see what needs to be done to treat the chest pain.
 
In this case, the EKG was performed for a reason separate and distinct from the reason/rationale for the cardiac procedure, and reporting the EKG with modifier -59 would be appropriate. Before appending modifier -59, you need to review and consider the individual circumstances for each situation—and that means the documentation has to reflect the full clinical picture and series of events.
 
CMS has noted inappropriate use of modifier -59 and published additional information on the application of the modifier in MLN Matters® MM8863, which provides additional guidance and examples of when the modifier is and is not appropriate. 
 
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.



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