Claim editing update for modifier 59 coming later this year to Medicare Plus Blue claims

As we communicated in an August Record article, we’ll begin editing claim lines when modifier 59 is appended on Medicare Plus Blue℠ claims. Following are additional details.

Background
The Centers for Medicare & Medicaid Services has established code pairs that identify procedure codes that are either mutually exclusive or incidental to one another, or that shouldn’t be reported together due to an overlap in services. We currently use the National Correct Coding Initiative, or NCCI, list as published by CMS.

This list indicates whether modifier 59 can be used to allow two codes to be billed together that would otherwise be denied. When we update the claims editing process, only select codes will allow modifier 59 to automatically bypass the NCCI code pair edits.

While the editing enhancements won’t take place until later this year, we encourage you to follow the guidelines provided in this article now.

Examples of billing scenarios

If you bill modifier 59 and receive a claim line denial, following are some examples of circumstances when it would be appropriate to appeal the denial by submitting medical records that demonstrate the services are separate and distinct:

Example 1:

• CPT code *17110 (Column I) – Destruction (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 
• CPT code *11102 (Column II) – Tangential biopsy of skin (for example, shave, scoop, saucerize, curette); single lesion

Modifier 59 may be reported with CPT code *11102 if the procedures are performed at different anatomic sites. For example, a lesion is biopsied by shave removal on the left forearm and a benign lesion was destructed on the cheek.

Modifier 59 shouldn’t be used if the procedures were performed on the same lesion.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures that aren’t ordinarily performed or encountered on the same day are performed on different organs, different anatomic regions or in limited situations on different, noncontiguous lesions in different anatomic regions of the same organ.

Example 2:

• CPT code *45385 (Column I) – Colonoscopy, flexible; with removal of tumors, polyps, or other lesions by snare technique
• CPT code *45380 (Column II) – Colonoscopy, flexible; with biopsy, single or multiple

Modifier 59 may be reported with CPT code *45380 if the procedures are performed at separate sites. For example, a polyp was removed in the transverse and descending colon by cold snare technique and a biopsy of a lesion was performed in the ascending colon by cold forceps.

Modifier 59 shouldn’t be used if both techniques are used to remove the same polyp, tumor or lesion.

Example 3:

• CPT code *88360 (Column I) – Morphometric analysis, tumor immunohistochemistry (for example, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual
• CPT code *88342 (Column II) – Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

Modifier 59 may be reported with CPT code *88342 if each procedure is for a different antibody. For example: A needle biopsy is performed on the left breast and an immunohistochemistry antibody stain procedure is performed using GATA3 and a morphometric analysis antibody stain procedure is performed using HER2.

Modifier 59 shouldn’t be used if the same antibody is used for each procedure.

Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day.

Example 4:

• CPT code *97113 (Column I) – Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
• CPT code *97110 (Column II) – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

Modifier 59 may be reported with CPT code *97110 if the two procedures are performed in distinctly different time blocks. For example, provider performs 15 minutes of therapeutic exercises from 11:30 to 11:45 and the provider performs 15 minutes of aquatic therapy with the patient from noon to 12:15 p.m.

Modifier 59 shouldn’t be used if both procedures were performed during the same time block.

Modifier 59 is used appropriately when two services describe nonoverlapping services even though they may occur during the same encounter. 

Example 5:

• CPT code *99213 (Column I) – Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and examination and low level of medical decision-making. When using time for code selection, 20 to 29 minutes of total time is spent on the date of the encounter.
• HCPCS code G0444 (Column II) – Annual depression screening, 15 minutes

Modifier 59 may be reported with HCPCS code G0444 as it’s a time-based procedure and is separate and significant from the E/M. For example, an E/M is conducted due to an ear infection and sore throat. The provider indicates a depression screening was performed for 15 minutes using the PHQ-9.

Modifier 59 shouldn’t be used if the documentation doesn’t indicate the time spent doing the depression screening.

Example 6:

• CPT code *01402 (Column I) – Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty
• CPT code *64447 (Column II) – Injections, anesthetic agents and/or steroid; femoral nerve

Modifier 59 may be reported with CPT code *64447 if the procedure is performed for post-operative pain management. For example, surgeon requests an injection for post-op pain management and the anesthesia is administered for the procedure. These two services are separate and distinct as they are being administered at separate times for separate reasons.

Modifier 59 shouldn’t be used if the injection wasn’t administered for post-operative pain management.

Modifier 59 is used appropriately for a diagnostic procedure that precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

Example 7:

• CPT code *92928 (Column I) – Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch
• CPT code *93458 (Column II) – Catheter placement in coronary arteries for coronary angiography, including intraprocedural injections for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injections for left ventriculography, when performed

Modifier 59 may be reported with CPT code *93458 if the diagnostic angiography hasn’t been previously performed and the decision to perform the angioplasty is based on the result of the diagnostic angiography.

Modifier 59 shouldn’t be used if the angiography isn’t performed diagnostically and is included or performed during the angioplasty.

Example 8:

• CPT code *37225 (Column I) – Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed
• CPT code *75710 (Column II) – Angiography, extremity, unilateral, radiological supervision and interpretation

Modifier 59 may be reported with CPT code *75710 if the diagnostic angiography hasn’t been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography.

Modifier 59 shouldn’t be used if the angiography isn’t performed diagnostically and is included or performed during the revascularization.

Modifier 59 is always appended to the Column II Code on the NCCI list.

This enhancement also applies to modifiers:

• XE – Separate encounter, a service that’s distinct because it occurred during a separate encounter
• XP – Separate practitioner, a service that’s distinct because it was performed by a different practitioner
• XS – Separate structure, a service that’s distinct because it was performed on a separate organ/structure
• XU – Unusual nonoverlapping service, the use of a service that is distinct because it doesn’t overlap usual components of the main service

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation that supports the procedures are separate and distinct. Also, continue to fax one appeal at a time to avoid processing delays.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.