Corporate Compliance

Note from the instructor: CMS Updates Special Edition Article on the Proper Use of Modifier -59

Medicare Insider, June 24, 2014

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CPCO,regulatory specialist for HCPro.

CMS has released an updated MLN Matters Special Edition article SE1418 on the proper use of modifier -59. This high-risk modifier has been the subject of much discussion within hospitals—both prospective payment system and critical access hospitals—and the subject of various audits by Medicare Administrative Contractors, Recovery Auditors, and the Office of the Inspector General (OIG).
For years, hospitals have been navigating the Procedure to Procedure (PTP) edits that were implemented under the National Correct Coding Initiative (NCCI). PTP edits are pairs of CPT or HCPCS Level II codes that are not both separately payable when billed by the same provider for the same beneficiary for the same date of service, unless an appropriate modifier is reported. Based on a Correct Coding Modifier Indicator (CCMI), certain modifiers will override an NCCI PTP edit and allow both services to be considered for separate payment.
However, CMS states that one of the functions of the NCCI PTP edits is to prevent payment for codes that report overlapping services, except in those instances where the services are “separate and distinct.” According to CMS and further confirmed by OIG audits, modifier -59 is often used incorrectly.
The previous article, SE0715, has now been replaced with SE1418. SE1418 describes three other “limited situations.” It also gives examples of when modifier -59 may be used if reporting two services as separate and distinct when they are performed during the same encounter. The following examples are given:
·         Modifier -59 is used appropriately for two services described by timed codes (i.e., per 15 minutes, per hour) when they are provided during the same encounter and only when they are performed sequentially (i.e., one service is completed before the subsequent service begins)
·         Modifier -59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
·         Modifier -59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure
Additional examples may be found on the NCCI Overview page, under the link “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service” although this article does not include the new CMS guidance. Further clarification can also be found in Chapter 1 of the NCCI Manual that states modifiers should only be appended to HCPCS/CPT codes if the clinical circumstances justify its use and that a modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit. If CMS imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the restrictions are fulfilled.
In discussing the proper application of modifiers with a variety of hospitals around the country, it seems like there are many different procedures and a variety of staff involved in this process. Coding and billing staff, auditing and compliance teams, and individual departments who have modifier -59 attached to HCPCS codes in the charge description master should all carefully review and discuss SE1418 to ensure the modifier is being used appropriately and proper payment is being received.

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