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Append modifier -59 to ED injection with appropriate documentation

APCs Weekly Monitor, August 4, 2006

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Append modifier -59 to ED injection with appropriate documentation

QUESTION: A patient presents to the ED with a finger laceration (883.0). The physician repairs the wound (12001) and gives the patient an intramuscular injection (90772) of Ancef ®. The NCCI edits indicate that the injection (90772) is a component of the comprehensive procedure (12001). Is it appropriate to append modifier -59 to 90772?

ANSWER: On January 1, 2006, CMS released updated information indicating that providers could append modifier -59 to injections/infusions provided in the ED. From January through March 2006, NCCI edits were disabled for injections and infusions in the ED. Then, from April through June 2006, CMS resurrected the NCCI edits for injections and infusions with multiple combinations requiring the use of modifier -59.

But based on hospital feedback, Medicare decided to release a limited pair of NCCI edits for injections and infusions beginning with Version 12.1 of the outpatient code editor effective July 1, 2006. For more information, read Medlearn Matters article SE0635 at the CMS Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0635.pdf

Even with the elimination of the most common drug administration code pairs, hospitals continue to see a combination of codes that evoke NCCI edits involving injection(s) or infusion(s) with procedures and services provided on the same date of service. The example above is a common set of code pairs that require providers to append modifier -59 to 90772 in order to receive APC payment. Again, documentation must be present for the use of modifier -59.

Continue to monitor your internal claims scrubber technology, encoder logic, and personnel to ensure a complete understanding of the updates and requirements for drug administration code pairs and the current NCCI edits in order to achieve APC revenue integrity.

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