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Use modifiers -59, -91 to "explain" duplicate codes

HCPro Coder Connection, November 17, 2004

Use modifiers -59, -91 to "explain" duplicate codes

Modifiers -59 and -91 can help hospitals reduce denials from Medicare fiscal intermediaries (FIs) when billing duplicate CPT codes or a single CPT code with multiple units of service. "When used appropriately, these modifiers can 'explain' the duplicate codes or multiple units to the FI," says Lolita Jones, RHIA, CCS, of Lolita M. Jones Consulting in Fort Washington, MD.

Modifier -91 indicates repeat clinical diagnostic laboratory services. The lab should use modifier -91 to indicate the completion of multiple clinical diagnostic lab tests for the same beneficiary on the same day.

Modifier -59 (distinct procedural service) may be used to indicate that the service is performed at a different anatomic site or at a different session, but on the same date. It may also represent a different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or even a separate injury.

The following case study involves repeat procedures. Please read the documentation, then test yourself on the use of modifiers -59 and -91.

Case study
A patient is seen in the ED. To assess the patient's medical condition, a physician orders a blood glucose meter (BGM) lab test (CPT code 82962). Later during the same visit, the physician orders a second BGM lab test (82962).

The two lab test reports confirm that the patient had the same two tests performed. Both lab test reports list the same abbreviated test name "GLUM," or glucose monitoring, but each lab test report has different "accession" and "result" numbers, confirming that these lab test reports were for different tests, not duplicate printouts of the same lab test report.

In addition, the patient has two injections performed during the visit. He receives 10 mg of the drug Compazine via an intramuscular injection (90782) and a subcutaneous injection of 5 units of insulin (90782).

The answers

The above codes reflect duplicate CPT code 82962 (for the initial and repeat BGM). Modifier -91 explains the repeat clinical lab tests ordered and performed (82962).

This bill also reflects duplicate CPT code 90782 (intramuscular or subcutaneous injection) for the separate IM injection, and the subQ injection that the patient received. Modifier -59 explains the multiple injections that were ordered and performed (90782).

(This week's HCProCoder Connection was adapted from the November 2004 Briefings on APCs.)