Health Information Management

Tip of the Week: Narrow your interpretation of modifier -59

APCs Insider, August 31, 2007

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It seems like modifier -59 (distinct procedural service) is the black sheep of the coding industry. Some choose to abuse it, because they think they can get away with it, whereas others shy away from it in fear.

CMS published a special edition MLN Matters article (SE0715) in May that attempts to clarify modifier -59's use above and beyond what the CPT Manual and CPT Assistant say.

In hopes of clearing this confusion, the MLN Matters article states that coders should report modifier -59 only for procedures performed at:

  • Different anatomic sites
  • Different patient encounters
"[The article] talks about the misuses where if there are two codes [on a claim] you could argue that they're two surgeries," says Kimberly Anderwood Hoy, Esq., JD, CPC, director of Medicare and compliance for HCPro, Inc., in Marblehead, MA. "But just because there are two codes, it doesn't mean that they're really separate surgeries, because one may have been integral to the other. They have to be at separate anatomic sites or separate patient encounters for modifier -59 to apply."

To view the MLN Matters article, click here.

(The above tip appeared in the September 2007 issue of Briefings on APCs).



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