Health Information Management

Don’t use modifier -59 for E/M codes

APCs Insider, March 20, 2009

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Q. Is it appropriate to append E/M codes with a modifier -59 (distinct procedural service)? The edit seems redundant and unnecessary. For example, the CCI edit hits for a code 1/code 2 pair for 99213 (or any level E/M) and 92014 (ophthalmologic exam). Another example is 96402 (chemotherapy administration, subcutaneous or intramuscular, hormonal anti-neoplastic) and 99213 (or any level E/M), and the E/M code is code 2 of the pair.

A. Do not use modifier -59 for E/M codes. In the case of the ophthalmologic exam (92014), the appropriate modifier is -27 (multiple outpatient hospital E/M encounters on the same date) if the service was a separate and distinct E/M service from the office visit. The modifier description focuses on separate departments, for example an office visit at a primary care clinic and an ophthalmologic exam at the eye clinic.

In the case of the chemotherapy service, the appropriate modifier is modifier -25 (significant, separately identifiable E/M service by the same physician on the same date of service) if the visit was significant and separately identifiable from the chemotherapy service. The modifier description focuses on the services being beyond the usual pre-op and post-op care associated with the chemotherapy service.

For more information, review CMS program memorandum A-00-40 and program memorandum A-01-80.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular