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Separate procedures key phrase for using modifier -59

Radiology Administrator's Compliance and Reimbursement Insider, April 1, 2006

If you're not sure when to use modifier -59, you're not alone. Many practices have difficulty interpreting guidelines for its use.

Known as the "last resort" modifier, you'll probably run into situations in which you'll need modifier -59 to get paid. Understanding the meaning of the term "separate procedures" can help you use the modifier appropriately. If you use it correctly, you'll be paid correctly.

First thing's first: Define modifier -59

The CPT manual says to use modifier -59 in situations in which "a procedure or service was distinct or independent from other services performed on the same day."

For a procedure to qualify for modifier -59, it must be distinguished by either session or patient encounter, procedure or surgery, site or organ system, incision or excision, lesion, or injury. Simply put, for separate and distinct procedures, use modifier -59.

That may be simply put, but as every radiology biller knows, using this modifier becomes tricky at times. When you're trying to decide whether to use modifier -59, ask yourself the following questions:

  • Is the procedure at a separate site, injury, or lesion?
  • Was the procedure performed in a separate session?

    If you believe the procedures are separate, you can justify your responses, and you have clear documentation proving this, use modifier -59. You should be paid for separate procedures.

    Following are three examples of how to use modifier -59:

    1. Two different procedures, same session, different sites. Consider selective catheter placements during an arteriogram, says RACRI advisor Jackie Miller, RHIA, CPC, consultant at Coding Strategies, Inc., in Powder Springs, GA.

    If you place a catheter into the left common carotid (a first order vessel) and left internal carotid (a second order vessel), you can't use modifier -59 to get paid for both because they are in the same vascular family.

    However, if you catheterize the left vertebral (a second order vessel) and left common carotid, you can charge for both because they are in different families.

    In this situation, modifier -59 tells the payer that the procedures are separate and that you should be paid separately for each.

    2. Two different procedures, same session, same site. Modifier -59 can occasionally be used for two services in the same location, as long as they are clearly two separate procedures, says Jo Ann Stiegerwald, RHIT, senior consultant for the Wellington Group in Cleveland.

    For example, it may sometimes be medically necessary for a physician to perform a fine-needle aspiration (FNA) and needle core biopsy of a lesion, Miller says.

    In this situation, it's appropriate to bill for both the needle core biopsy and the FNA, as long as you document both services appropriately.

    Use modifier -59 on the FNA to avoid having it bundled with the core biopsy.

    Nevertheless, be careful when using modifier -59 to bill for two procedures performed during the same session and in the same location.

    3. Two different procedures, same site, different sessions, same day. If a physician performs two separate procedures on one patient during the same day, then use modifier -59 to bill separately.

    The procedures must be separate and distinct, and you must be able to prove that the two procedures were performed separately.

    Billers can also use modifier -59 when a physician performs two different procedures in one location at different times on the same day, says Laureen Jandroep, owner, consultant, and instructor at A+ Medical Management and Education in Egg Harbor City, NJ.

    For example, if the patient has an acute abdomen series (74022) in the morning and returns to the radiology department for a single-view abdomen (74000) later that day because he still has pain, you could use modifier -59.

    Unless you use modifier -59 to show that the procedures were performed during separate encounters, the single-view abdomen would be bundled into the acute abdomen series.

    Code bundling and modifier -59

    Use modifier -59 when an ordinarily bundled service is done at a different anatomic site or during a different session on the same day.

    Keep an updated copy of the National Correct Coding Initiative (NCCI) edits handy, Stiegerwald says. There you can find information that describes bundled procedures and the circumstances under which bundled procedures can be billed separately.

    "[Billers] have to know the bundling edits, and they have to know the circumstances of the surgery," says Stiegerwald. "If all the surgery was done in the same encounter, the bundling edits themselves will tell them whether this procedure can be billed out separately."

    Practices should refer to the NCCI edits before sending their claims to make sure that everything that needs to be bundled is and that all procedures billed separately are truly separate procedures.

    Editor's note: Portions of this text were taken from HCpro publications justcoding.com, published in April 2005, and The Doctor's Office, published in August 2003.