Health Information Management

Tip: Understand OIG’s scrutiny of modifier -59

APCs Insider, November 21, 2014

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

In 2005, the Office of Inspector General (OIG) released a report studying the modifier's application, "Use of Modifier -59 to Bypass Medicare's National Correct Coding Initiative Edits." OIG found that 40% of code pairs billed with modifier -59 (distinct procedural service) in 2003 did not meet program requirements, leading to $59 million in improper payments. Most of the errors were due to services that were not distinct from each other or not documented sufficiently.
 
As a result of the study, OIG recommended that carriers perform pre- and post-payment reviews of modifier -59 use, as well as update their claims processing systems to ensure they bill the modifier with the correct code in a pair.
 
Since then, the OIG has continued to study modifier -59 and make recommendations to CMS on how to ensure providers use it correctly. CMS continued to offer guidance on its use, and indicated to OIG in December 2009 that it would explore development of a system edit for modifier -59. However, CMS abandoned this route after determining that an edit for modifier -59 would result in increased appeals volume.
 
Over the next several years, CMS continued to indicate to OIG that it would explore alternatives in order to ensure correct modifier application. In Transmittal 1422, CMS states that modifier -59 is:
  • Infrequently (and usually correctly) used to identify a separate encounter
  • Less commonly (and less correctly) used to define a separate anatomic site
  • More commonly (and frequently incorrectly) used to define a distinct service
This tip is adapted from “CMS introduces four new subsets of modifier -59” in the November issue of Briefings on APCs.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular