Health Information Management

Q&A: Appending modifier -59 for critical care

APCs Insider, December 14, 2012

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Q: We have been reporting services, such as chest x-rays and pulse oximetry, on critical care patients seen in our ED. Most of these patients are transferred to a higher level of care, but they may be in our ED for an hour or more. I see the codes reported sometimes without modifier -59 (distinct procedural service) and then other times with modifier -59. What is correct way to report them under OPPS?

A: The following ancillary services are noted in the CPT® Manual as included in critical care (CPT 99291,99292):
  • Interpretation of cardiac output measurements (93561, 93562)
  • Chest x-rays (71010, 71015, 71020)
  • Pulse oximetry (94760, 94761, 94762)
  • Blood gases and information data stored in computers (eg, ECGs, blood pressures, hematologic data (99090)
  • Gastric intubation (43752, 91105)
  • Temporary transcutaneous pacing (92953)
  • Ventilatory management (94002-94004, 94660, 94662)
  • Vascular access procedures (36000, 36410, 36415, 36591, 36600)
According to the note under this listing, this inclusion is in reference to coding for professional services; facilities should report the ancillary services separately.
There is a difference in reporting services and receiving payment for services. CMS has provided guidance over the past several years that the payment for these services is included in the payment for CPT code 99291.
Modifier -59 indicates that a service/test/procedure is separate and distinct from another service/procedure. If you append modifier -59 to the code for the ancillary service, you are telling CMS (and any other payer) that the service is separate and distinct from the critical care encounter. In the scenario you describe, this is not the case – the ancillary services were provided as part of the critical care encounter.
Based on CMS’ guidance, you can report the ancillary services listed above; however, you should not append modifier -59 to the services when they are directly related to the critical care service. Per CMS guidance, modifier -59 is appended only when the service is provided at a different encounter on the same date of service.
Below is an excerpt from CMS Transmittal 2141:
Beginning January 1, 2011, in accordance with revised CPT guidance, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing CPT codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged. The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services does not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.
Modifier -59 would be appropriate, for example, if the patient came to the hospital for a chest x-ray in the morning and was seen in the ED later in the same day for a critical care event. Because all outpatient services are reported on one claim for a date of service, the charges would all be included on the same claim. Modifier -59 would be appropriate for the chest x-ray to indicate that it was performed on the same day but totally separate from the critical care service.
This is difficult for some facilities to implement because the internal scrubber won’t allow the services to pass through the system without removal or appending of a modifier. If this is the case, review the internal scrubber edit to ensure that the services can be reported to payers in order to capture all cost/resources provided to a patient. If line items are removed because the edit cannot be bypassed, the cost/resource information is not passed on to CMS and never taken into consideration for APC payment calculations.
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.

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