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New CMS transmittal clarifies drug administration, modifier -59

APCs Weekly Monitor, April 14, 2006

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New CMS transmittal clarifies drug administration, modifier -59

CMS Transmittal 902, dated April 7, 2006, put in writing some of the answers that providers have sought regarding drug administration since its initial publication of Transmittal 785 in December 2005. Following is a summary of its contents.

Clarification of C8952
Although a CMS FAQ published February 2006 stated that providers can only report C8952 for new substances/drugs, CMS took it one step further when it stated the following in the more recent April transmittal:

Additional IV pushes of the same substance or drug are not separately reported with multiple units of a push code because the number of units reported with the IV push code is to indicate the number of separate substances or drugs administered by the IV push.

Options for reporting packaged supplies
Transmittal 785 also had instructed that providers should not separately bill use of local anesthesia, IV start, flushes, and other routine services. However, Transmittal 902 adds that providers have one of two choices when identifying these services:

• Continue to report separate charges so long as the charges are reported without a CPT/HCPCS code, but rather are reported with an appropriate packaged revenue code or;
• Do not report any separate charges but include the charges for the items and services as part of the charge for the procedure in which the items/services are supplied.

Appropriate use of modifier -59
In Transmittal 902, CMS also provided the following additional criteria for appending modifier -59:

A distinct and separate drug administration service is provided on the same day as a procedure when there is an OPPS National Correct Coding Initiative edit for the drug administration service and procedure code pair that may be bypassed with a modifier, and the use of the modifier is clinically appropriate.

Although this is good news in terms of being able to report and get paid for multiple drug administration services provided during a single encounter, the problem is that OPPS providers will find themselves using modifier -59 more often than not, says Jugna Shah, MPH, president of Nimitt Consulting in St. Paul, MN.

For example, when a provider performs a non-chemotherapy infusion (C8950) and a non-chemotherapy IV push injection (C8952) during the same encounter, he or she must use modifier -59 in order to be paid appropriately for both services. "Providers will see a huge increase in their use of modifier -59, which is not great, given that this modifier is thought to be a modifier of last resort and one that the OIG is scrutinizing," Shah says.

The other criteria for which a provider might append modifier -59 include

• The drug administration occurs during a distinct encounter on the same date of service of previous drug administration services; and
• The same HCPCS code has already been billed for services provided during a separate and distinct encounter earlier on the same day

You can view Transmittal 902 at the CMS Web site: http://www.cms.hhs.gov/transmittals/downloads/R902CP.pdf

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