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Expect relief from modifier -59 with drug administration claims

APCs Weekly Monitor, May 26, 2006

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Expect relief from modifier -59 with drug administration claims

QUESTION: Here is a drug administration scenario I'm hoping you could examine to help me clarify the appropriate use of modifier -59. A patient arrives at the hospital and staff provides the following services during a single encounter:

• Four hours of chemotherapy (C8954, C8955 x3)
• Two hours of hydration (C8950, C8951)
• One Chemotherapy IV push (C8953)
• One non-chemotherapy subcutaneous injection (90772)
• One non-chemotherapy IV push (C8952)

Is it appropriate to append modifier -59 to C8950, C8953, 90772, and C8952? We are currently holding an enormous number of claims and need specific guidance so we can send these claims out correctly.

ANSWER: Due to the new CCI edits valid as of April 1, you must append modifier -59 to the following codes in order to receive your entitled reimbursement:

• C8950-59
• C8953-59
• 90772-59
• C8952-59

To help ease the massive back log of denied claims, Medicare released a May 17 Medlearn Matters special edition article SE0635 "Processing of OPPS claims with certain drug administration code pairs." You can find the article at the CMS Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0635.pdf

The article states that FI's will automatically append modifier -59 to six drug administration code pairs currently subject to the CCI edits, but that there is no effective date and hospitals will have to first be notified by their own FI.

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