CODING Q&A

Clarifying the Issues Surrounding Modifier 59

BY SUZANNE L. CORCORAN, COE

Modifier 59 is the “unbundling” modifier. Much confusion and controversy have accompanied its use. We’ll try to clarify the issues.

Q. HOW IS MODIFIER 59 DEFINED IN CPT?

A. CPT defines modifier 59 as a “Distinct Procedural Service.” CPT explains, “Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

Q. WHEN SHOULD ONE USE MODIFIER 59?

A. It’s used in circumstances where the Medicare National Correct Coding Initiative (NCCI) edits or the CPT “separate procedure” rule should not apply, and separate reimbursement is justified. Examples follow.

Different session: A service in the morning and another in the evening of the same day (eg, in the same practice, fundus photography [92250] in the morning and ICG angiography [92240] in the afternoon by a retina specialist not available in the morning). Note that 92250 generally bundles with 92240 on a claim for reimbursement.

Different surgery: Surgery in the morning a second surgery in the evening of the same day (eg, vitreous tap [65810] in the morning to detect microorganisms and then vitrectomy [67036] in the evening in the same eye). Note that 65810 generally bundles with 67036 on a claim for reimbursement.

Different site: Surgery on one eye and another surgery on the other (eg, retinal detachment repair OD [67108] and prophylaxis of retinal tear OS [67145]). Note that 67145 generally bundles with 67108 on claims for reimbursement.

Separate injury: Repair of one injury on the right side and another injury on left side (eg, airbag injury to both eyes, repair of retinal detachment [66852], OD, and posterior vitrectomy and lens extraction for dislocated lens [67108], OS). Note that 66852 generally bundles with 67108 on a claim for reimbursement.

Q. CAN A CLAIM APPLY THIS MODIFIER WITH OTHERS?

A. Sometime, but not usually. The CPT definition states, “… when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used.”

An exception is the use of informational modifiers, such as RT and LT, to indicate the right or left eye.

Q. CAN YOU USE MODIFIER 59 TO GET AROUND THE NCCI EDITS IF EACH PROCEDURE HAS A DISTINCT INDICATION AND IS PREPLANNED?

A. No. According to Medicare’s MLN Matters (SE0715), “Use of modifier 59 … does not require a different diagnosis for each HCPCS/CPT code procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.”

For example, unbundling fundus photography (92250) and OCT of the retina (92134) using modifier 59 is not justified by two different diagnoses.

Q. ARE DIFFERENT AREAS OF THE RETINA CONSIDERED DIFFERENT ANATOMIC SITES?

A. No. Medicare is quite specific about this: “The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. … Treatment of posterior segment structures in the eye constitute a single anatomic site.”

For example, prophylaxis of retinal tear (67145) bundles with complex retinal detachment repair (67113), even when the tear is far away from the detachment in the same eye. RP