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OIG: Physicians and therapists are using modifier 59 incorrectly

Rehab Regs, December 23, 2005

The Office of Inspector General (OIG) recently released a report that found that 40% of code pairs billed with modifier 59 in fiscal year 2003 did not meet program requirements, resulting in $59 million in improper payments because Medicare allowed payments for 40% of the code pairs despite not following program requirements. In 15% of the cases, modifier 59 was used inappropriately because the services were not distinct from each other.

The OIG is recommending that the Centers for Medicare & Medicaid Services (CMS) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59.

The study consisted of a random sample of 350 code pairs for services that bypassed correct coding initiative edits.

CMS says it will distribute the report to its contractors responsible for identifying improper payments and potential fraud, waste, and abuse, while also issuing an article to provide continuing education to physicians and therapists on how to bill modifier 59 properly.

The complete OIG report can be found here.

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