Health Information Management

Simplify the decision to use modifier -59

JustCoding News: Outpatient, August 22, 2012

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A surgeon performs a diagnostic shoulder arthroscopy before repairing a patient’s rotator cuff. The surgeon knew ahead of time that he or she would be repairing the rotator cuff. Should a coder or biller append modifier -59 (distinct procedural service) to the CPT® code for the diagnostic shoulder arthroscopy to ensure reimbursement for both procedures?

Most coders and billers probably know that they cannot unbundle those two procedures. According to the CPT guidelines and the NCCI edits, the diagnostic arthroscopy is part of the surgical procedure.

What if the surgeon performs a diagnostic shoulder arthroscopy and finds the patient has a torn rotator cuff? The surgeon decides to repair the injury during that operative session rather than bring the patient back for a separate procedure. Is it appropriate to report modifier -59 for this diagnostic arthroscopy? After all, the surgeon didn’t plan on performing any additional procedures.

The answer is still no because the surgeon performed the repair during the same session. The NCCI edits state that if a diagnostic arthroscopy leads to a surgical arthroscopy during the same patient encounter, facilities may only charge for the surgical procedure, says Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, executive vice president for Med Law Advisors, Inc., in Atlanta.

Proper use of modifier -59
Modifier -59 indicates a:

  • Different surgical session
  • Different procedure or surgery
  • Different site or organ system
  • Separate excision or incision
  • Separate lesion or injury

It may be appended to radiology, surgical, and other services as appropriate. Coders should not append modifier -59 when another modifier better describes the circumstances (e.g., -FA, -LT, or -RT), says Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president/CEO and principal consultant for SLG, Inc., in Raleigh, N.C.

Coders should never use modifier -59 just to override an NCCI or medically unlikely edit, Goodman adds.

Facilities need to receive appropriate reimbursement for the services they provide, Garrison says. In order to be properly reimbursed, facilities must:

  • Know what should be paid
  • Know how the service should be documented
  • Know how the service should be coded and billed
  • Know how the service should be reimbursed
  • Challenge inappropriate reimbursement

As always, the documentation must support the use of modifier -59 or any other modifier, Garrison says.

Alternatives to modifier -59
Modifier -59 should always be the modifier of last ¬resort, Goodman says. Before appending modifier -59, coders and billers should first check that no other ¬modifier will better describe the patient’s situation. If a better modifier exists, use it, Garrison adds.

In some cases, coders will append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) instead of modifier -59. Modifier -58 indicates that a procedure was followed by another procedure or service during the postoperative period. This may be because it was planned prospectively, because it was more extensive than the original procedure, or because it represents therapy after a diagnostic procedural service.

For hospital outpatient billing, coders and billers should only use modifier -58 on the same date as the original procedure, Garrison says. It becomes unnecessary later.

Be sure to read the individual chapter guidelines closely to ensure correct use of modifier -58, Garrison says. Proper use can be tricky.

For example, a patient undergoes a breast biopsy. The surgeon sends the biopsy for a frozen section, and then performs a mastectomy based on the biopsy results during the same operative session. In this case, a coder should append modifier -58. “That way you get paid for the biopsy instead of it being bundled into the mastectomy,” Garrison says.

In other situations, providers need to repeat a procedure on the same day, but during a different session. In such a case, a coder can choose between these three modifiers:

  • Modifier -76, repeat procedure or service by the same physician or other qualified healthcare professional
  • Modifier -77, repeat procedure or service by another physician or other qualified healthcare professional
  • Modifier -91, repeat clinical diagnostic laboratory test

Coders append modifiers -76 and -77 for ¬procedures, radiology services, and diagnostics. They report modifier -91 for clinical laboratory procedures.

Each service repeated must be medically necessary, Garrison says. For example, the repeat laboratory test must be to obtain subsequent reportable test values. Modifier -91 would not be used:

  • In the event of poor specimen collection
  • To validate original results
  • For stat results when the original has not yet been received
  • If another code can capture all the services

The provider must document that the laboratory service or procedure was distinct or separate from other services performed on the same day, Garrison says.

Many facilities struggle when choosing between modifiers -59 and -91, Garrison contends. CPT Assistant attempted to clarify the situation. According to that publication, use modifier -59 when different types of specimens are obtained and when the tests are run simultaneously, concurrently, or in separate sessions on the same date to obtain multiple results. “Different types of specimens” is the key phrase here, Garrison says.

Use modifier -91 when the physician ¬specifically wants to repeat the same lab test with the same specimen type on the same date to see whether the result is different.

“They want to run the same test and they want to use the same type of specimen,” Garrison says. “They are going to get a new specimen, but it’s the same type of specimen.”

Modifier -59 and the integumentary system
Consider some common situations that might require coders to append modifier -59.

A patient comes in with multiple lesions that the physician plans to excise. The physician can use multiple different techniques, including destruction (e.g., laser, freezing), debridement, paring/cutting, shaving, or excision.

According to the NCCI guidelines, facilities may only report one removal code per lesion. If the physician removes multiple lesions in a single procedure (e.g., single excision of skin containing three nevi), facilities should only report one code.

“You want to make sure you look at the CPT code to see whether it covers multiple sites,” Garrison says. For example, the CPT codes for shaving of epidermal or dermal lesions (11300–11313) specify a single lesion in the code description. However, code 17110 (destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) covers multiple lesions.

If the physician starts the removal using one method, but converts to another method to complete the procedure, only report the code that describes the completed procedure. “They are only going to pay you for the successful procedure,” Garrison says.

If multiple lesions are removed separately, coders can often report multiple codes, depending on the CPT code and the type of procedure the provider performs, Garrison says. In these cases, coders should append the appropriate anatomical modifiers or modifier -59 to indicate different sites or lesions. The medical record must document the appropriateness of reporting multiple HCPCS/CPT codes with these modifiers.

Lesion removal includes obtaining a biopsy, as well as simple and intermediate-level repairs. If the physician must debride the wound prior to removing a lesion, the debridement is also bundled into the lesion removal.

Modifier -59 and radiology
A patient presents to the interventional radiology department for ultrasound-guided needle biopsies of two right breast lesions. The physician performs the biopsies during a single operative session.

Coders should only report one unit of code 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) even though two needles were placed. No modifier is necessary, Goodman says.

According to the NCCI edits, CMS payment policy allows one unit of CPT codes 76942, 77002, 77003, 77012, and 77021 during a single patient encounter regardless of the number of needles placed.

Now consider this example: A patient has a SAVI® breast device implanted and then presents for twice-daily HDR brachytherapy treatment (CPT code 77786). The CMS medically unlikely edit guidelines allow three units of code 77786, so coders should report code 77786 and a quantity of two units. No modifier should be required, Goodman says.

Keep in mind that this is not a bundling edit, she adds. The treatment is a repeat service on the same date, so coders should not append modifier -59 unless ¬written payer guidelines specifically require its use. Consider appending modifier -76 instead of modifier -59 if a payer directs facilities to report a modifier.

Editor’s note: This article was originally published in the August issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at


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