Health Information Management

Clarifying drug administration with modifier -59

APCs Insider, February 11, 2005

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Clarifying drug administration with modifier -59

Today's topic is not a Q/A, but clarifies some confusion about the new CPT infusion codes 90780 and 90781, and the use of modifier -59.

The APCs Weekly Monitor from Jan. 14, 2005, said the following of billing codes 90780 and 90781: "Do not use modifier -59. The example under section H of the Internet-Only Manual chapter 4, section 230.1 is incorrect, and will be corrected soon."

Here's what we know: The text in CMS Transmittal 404 ("January 2005 Update of the OPPS: Changes to Coding and Payment for Drug Administration") that describes the appropriateness of modifier -59 is CMS policy, but contradicts the example CMS provides in Section H.

This contradiction of text and example was raised during a January 2005 Open Door Forum call with CMS. CMS verbally responded by stating that the use of modifier -59 in the Section H example was an error and would be corrected. This information was the basis for the Jan. 14 Monitor statement, quoted above. CMS has not released a correction to date.

Jugna Shah, MPH, president of Nimitt Consulting in St. Paul, MN, followed up on the issue during the February 3 Open Door Forum. CMS staff stated they are aware of the error in the Transmittal's example and are still working on releasing an updated Transmittal. CMS stated that it has not released anything yet because it wants to hear all of the issues and questions providers have so they can be addressed all at once.

"Between the contradictory information provided in Transmittal 404 on drug administration (text statements vs. the example in Section H), all of the different information in the industry, and the verbal information shared by CMS in two Open Door Forum calls, it is no wonder that providers are confused," Shah says.

The open question for many providers is whether to follow the text, or the example in Section H of the Transmittal and report multiple infusion sites (e.g., two infusions running through two lines in two separate IV start locations) during the same visit using modifier -59, or not. If you follow the Transmittal instruction as discussed in the example, you may be paid for two infusions because the presence of modifier -59 generates an APC payment for each code 90780 through the OCE.

But if a correction is released that does not allow the use of modifier -59 (as CMS stated in the Open Door Forum), you may have to pay back money.

"Until CMS releases a correction to Transmittal 404, providers have a couple of choices about how they proceed with their claims submission. They can either (a) send in claims with modifier -59 for multiple IV infusion sites during the same visit, (b) hold claims until clarification is released, or (c) check with their FI about how to use modifier -59," Shah says.

Stay tuned for more information and clarification from CMS on modifier -59 and other drug administration topics.

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