Modifier 59 break bundles when you should
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The document provides guidance on using modifier 59 to report procedures that are not normally bundled but are appropriate to bill separately in certain circumstances, such as when they are performed at different session, for a different diagnosis, or require a separate incision. It outlines the rules for using modifier 59 and provides examples of its proper use in orthopedic, ob-gyn, and other clinical scenarios. Overall, the document aims to help providers understand when and how to appropriately "break bundles" using modifier 59.
![Orthopedic Case Study 1Orthopedic Case Study 1
A key point in the op report is that the surgeon began with an
arthroscopic debridement of the large labral tear. You should begin
with 29823 (Arthro sco py, sho ulde r, surg ical; de bride m e nt,
e xte nsive ), although you’ll need to append a modifier when you add
other codes. You should then address the open rotator cuff repair,
using 23412 (Re pair o f rupture d m usculo te ndino us cuff [e . g . , ro tato r
cuff] o pe n; chro nic).
How to decide between 23410 and 23412: If you choose 23410 (...
acute ) instead of 23412, you will gain about $60 more
reimbursement for this part of the surgery, but “acute” is not
appropriate in this case. He’s been having this pain for over six
months. “Acute” describes pain that began more recently, certainly
within the past six months.](https://image.slidesharecdn.com/modifier59-breakbundleswhenyoushould-101124054925-phpapp02/85/Modifier-59-break-bundles-when-you-should-19-320.jpg)
![Orthopedic Case Study 1Orthopedic Case Study 1
Now look to the arthroscopy codes. The next codes on your claim
should be 29824-51 (... distalclavicule cto m y including distal
articular surface [Mum fo rd pro ce dure ]; Multiple pro ce dure s ) and
29826-59 (... de co m pre ssio n o f subacro m ialspace with partial
acro m io plasty, with o r witho ut co raco acro m ialre le ase ; Distinct
pro ce duralse rvice ).
Why modifier51 and 59? The Correct Coding Initiative (CCI)
bundles 29826 into 23412, but you can override that edit in this
case with modifier 59. CCI does not bundle 29824 with 23412, so
you don’t need modifier 59 to override that edit. You simply need
modifier 51 to indicate multiple procedures. Keep in mind that some
payers’ software, such as with Medicare’s, automatically applies
modifier 51 for multiple procedure claims. Ask your payers whether
you need to use this modifier.](https://image.slidesharecdn.com/modifier59-breakbundleswhenyoushould-101124054925-phpapp02/85/Modifier-59-break-bundles-when-you-should-20-320.jpg)
![Ob-gyn Case Study 1Ob-gyn Case Study 1
One of your ob-gyn’s regular patients is having twins, and your ob-
gyn delivers them both vaginally. Two deliveries, however, do not
mean you should submit two global ob codes.
Reality: You should report the global code (59400) for the first baby
and 59409-51 (Vag inalde live ry o nly [with o r witho ut e pisio to m y
and/o r fo rce ps]; Multiple pro ce dure s ) for the second.
Heads up: You should know your payer’s preferences. Some
insurance companies instead prefer that you bill the additional
delivery with modifier 59 (Distinct pro ce duralse rvice ) attached.
Other payers will not pay anything additional for twin B when the
delivery is vaginal.](https://image.slidesharecdn.com/modifier59-breakbundleswhenyoushould-101124054925-phpapp02/85/Modifier-59-break-bundles-when-you-should-25-320.jpg)
Modifier 59 break bundles when you should
- 1. MODIFIER59 BREAK BUNDLES WHEN YOU SHOULDBREAK BUNDLES WHEN YOU SHOULD Jen Godreau, BA, CPC, CPEDC, Content DirectorJen Godreau, BA, CPC, CPEDC, Content Director Mary Compton, PhD, CPC, Editorial DirectorMary Compton, PhD, CPC, Editorial Director Suzanne Leder, BA, M.Phil, CPC, COBGC, Editorial ManagerSuzanne Leder, BA, M.Phil, CPC, COBGC, Editorial Manager The Coding Institute, LLC . SuperCoder.comThe Coding Institute, LLC . SuperCoder.com
- 2. Are rats smarter than humans?
- 3. Get Allowed Payment FasterGet Allowed Payment Faster Goals Bust bundles Recognize allowed boosters Use reducers when necessary Benefits Identify services that are eligible for separate payment Avoid dangerous unbundling habits Stop wasting time on unnecessary appeals
- 4. OIG 59 FindingsOIG 59 Findings • 15% performed at same session/site/incision • Ex: chemotherapy, IV infusion • 25% lacked supporting service(s) documentation • 11% used 59 on primary code, instead of secondary code • 13% had 59 on both codes
- 5. Modifier59: The BundleModifier59: The Bundle BreakerBreaker
- 6. CCI OriginsCCI Origins National Correct Coding Initiative (CCI) Created by Centers for Medicare and Medicaid Services (CMS) Purpose: To apply CPT coding conventions Sometimes does, Sometimes doesn’t
- 7. CCI SystemCCI System Column 1 Comprehensive Column 2 ComponentIncludes Critical care 99291 Pulse Ox 94760Includes
- 8. ExceptionsExceptions Some edits allow a modifier to override a bundled pair Modifier Indicators: “0” — No modifier allowed “1” — Modifier allowed Unusual circumstance must warrant separate reimbursement Unusual circumstance must warrant separate reimbursement “… Modifier 59 is used to identify services/procedures, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.” So urce : CPT 20 0 9 Appe ndix A
- 9. Circumstance CriteriaCircumstance Criteria Documentation must support a: different session different procedure or surgery different site or organ system separate incision/excision separate lesion separate injury (or area of injury in extensive injuries) CPT 20 0 8 re vise d fro m “m ay re pre se nt” to “m ust suppo rt”.
- 10. Alternative ‘Breaker’ ModifiersAlternative ‘Breaker’ Modifiers United HealthCare (UHC) allows you to break a bundle with these modifiers: 58, 59, 78, 79, 91 E1, E2, E3, E4 LC, LD, LT, RC, RT TA, T1, T2, T3, T4, T5, T6, T7, T8, T9 FA, F1, F2, F3, F4, F5, F6, F7, F8, F9 Nail avulsion (11730) on right ring finger and evacuation of blood under nail (11740) on right middle finger Bundle breaker: 11730-F8, 11740-F7 Nail avulsion (11730) on right ring finger and evacuation of blood under nail (11740) on right middle finger Bundle breaker: 11730-F8, 11740-F7 So urce : CCIEditing Po licy
- 11. Reserve 59 for2 ProceduresReserve 59 for2 Procedures shows service or procedure separate from E/M service 1 service, 1 procedure shows procedure or service distinct or independent “from other non-E/M service performed on the same day …” 1 procedure, 1 procedure Modifier 25 Modifier 59 So urce : CPT 20 0 9 Appe ndix A CPT 2008 added CPT 2008 added
- 12. Modifier59 RulesModifier59 Rules 1. Append to non-E/M codes only 2. Not normally reported together, but appropriate under circumstances Different site or location 1. No more descriptive modifier applies
- 13. ECG, Unrelated ProcedureECG, Unrelated Procedure CCI 15.1 bundled ECG codes 93000-93010 into Wart removal (17110) In/out catheterization (51701) Removal of impacted cerumen (69210) Use 59 on component code when different reason Use 59 on component code when different reason
- 14. Test YourselfTest Yourself A patient comes into have a wart removed (17110) and at the visit complains of chest pain. To evaluate the patient’s chest pain, the physician takes a history, performs an exam, and as part of medical decision making orders an in-office ECG to evaluate the patient’s chest pain (ECG). The physician documents his interpretation of the ECG reading as revealing no heart-related problems. Should you code the ECG? Answer: A. Yes. ECG is for a different reason than the wart removal so you can report the ECG. • 9921x, 786.59 (Che st pain; o the r) • 17110, 078.10 (Viralwarts, unspe cifie d) • 93000-59, 786.59 Answer: A. Yes. ECG is for a different reason than the wart removal so you can report the ECG. • 9921x, 786.59 (Che st pain; o the r) • 17110, 078.10 (Viralwarts, unspe cifie d) • 93000-59, 786.59
- 15. Is InhalerEducation & TrainingIs InhalerEducation & Training OK?OK? Col 1 RVUs Col 2 RVUs 94640 0.38 94664 0.39 Inhalation treatment Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device
- 16. Is Training at SeparateIs Training at Separate Session?Session? Code only treatment Occurs during treatment Staff/physician shows steps while patient receiving treatment 9921x(25), 94640 Code treatment, training 1. Patient receives treatment Rescue medication 1. MD decides education necessary 2. Staff does training Maintenance medication 9921x(25), 94640, 94664- 59 No, occurs during treatment Yes, occurs aftertreatment
- 17. Combat Denials With AmmoCombat Denials With Ammo “Typically, code 94640 does not include patient education. If separate medication instruction occurs on the same day as an initial aerosol treatment (e . g . , a different formof inhalerrequiring education), code 94664 can be used with a 59 modifier to indicate the distinct procedural service.” -- Steve G. Peters, MD, FCCP “Continuous Bronchodilator Therapy,” Che st (2007; 131; 286-289) published by the American College of Chest Physicians Dept of IM, Div of Pulmonary & Critical Care Medicine at Mayo Clinic ~ Rochester, Minn. Tool
- 18. Orthopedic Case Study 1Orthopedic Case Study 1 A 61-year-old male general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem. The orthopedist’s physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear. The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.
- 19. Orthopedic Case Study 1Orthopedic Case Study 1 A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear. You should begin with 29823 (Arthro sco py, sho ulde r, surg ical; de bride m e nt, e xte nsive ), although you’ll need to append a modifier when you add other codes. You should then address the open rotator cuff repair, using 23412 (Re pair o f rupture d m usculo te ndino us cuff [e . g . , ro tato r cuff] o pe n; chro nic). How to decide between 23410 and 23412: If you choose 23410 (... acute ) instead of 23412, you will gain about $60 more reimbursement for this part of the surgery, but “acute” is not appropriate in this case. He’s been having this pain for over six months. “Acute” describes pain that began more recently, certainly within the past six months.
- 20. Orthopedic Case Study 1Orthopedic Case Study 1 Now look to the arthroscopy codes. The next codes on your claim should be 29824-51 (... distalclavicule cto m y including distal articular surface [Mum fo rd pro ce dure ]; Multiple pro ce dure s ) and 29826-59 (... de co m pre ssio n o f subacro m ialspace with partial acro m io plasty, with o r witho ut co raco acro m ialre le ase ; Distinct pro ce duralse rvice ). Why modifier51 and 59? The Correct Coding Initiative (CCI) bundles 29826 into 23412, but you can override that edit in this case with modifier 59. CCI does not bundle 29824 with 23412, so you don’t need modifier 59 to override that edit. You simply need modifier 51 to indicate multiple procedures. Keep in mind that some payers’ software, such as with Medicare’s, automatically applies modifier 51 for multiple procedure claims. Ask your payers whether you need to use this modifier.
- 21. Orthopedic Case Study 1Orthopedic Case Study 1 Your final codes should look like this: 23412 for the open rotator cuff repair 29826-59 for the arthroscopic acromioplasty 29824-51 for the arthroscopic distal clavicle excision 29823-59 for the arthroscopic extensive debridement.
- 22. Orthopedic Case Study 2Orthopedic Case Study 2 A 21-year-old male who was struck by an automobile while riding his bicycle presents to the ED with a serious crush injury to the left lower extremity with massive swelling, ecchymosis, loss of sensation in the foot, and tightness of all four lower leg compartments and of the foot. He also complains of left elbow and shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left calcaneal fracture, left radial head fracture, and clavicle fracture. The orthopedist admits the patient. The patient undergoes immediate surgery to stabilize his fracture and treat his acute compartment syndromes of the lower leg and foot. The surgery involves a closed reduction of the tibial plateau fracture with application of an external fixator. The orthopedist plans open treatment of this fracture and the calcaneal fracture once the patient’s fasciotomy wounds are closed.
- 23. Orthopedic Case Study 2Orthopedic Case Study 2 The code with the highest relative unit will be the code for the closed treatment of the tibial fracture 27532-LT (Clo se d tre atm e nt o f tibialfracture , pro xim al(plate au); with o r witho ut m anipulatio n, with ske le taltractio n; Le ft side ). Next, report 20690-51-LT (Applicatio n o f a uniplane (pins o r wire s in o ne plane ), unilate ral, e xte rnalfixatio n syste m ; Multiple pro ce dure s; Le ft side ). After that, you should report the decompression leg fasciotomy code. Depending on the compartments released, you would report 27600 for anterior and lateral, 27601 for posterior only, or 27602 for anterior and/or lateral and posterior. You’ll most likely report 27602, because the scenario describes all four compartments as tight. Depending on insurer, you might need modifier 51 on 27602. You can also apply modifier LT. For the fasciotomy, you should report 28008-51 (Fascio to m y, fo o t and/o r to e ).
- 24. Orthopedic Case Study 2Orthopedic Case Study 2 Question: Should you rule out adding modifier 59 to this claim? Answer: Yes. Neither code has “separate procedure” designation, and the combination isn’t normally bundled. Adding modifier 59 to this claim is inappropriate because payers following CCI edits do not normally bundle these code combinations, nor do the codes have “separate procedure” designations. Answer: Yes. Neither code has “separate procedure” designation, and the combination isn’t normally bundled. Adding modifier 59 to this claim is inappropriate because payers following CCI edits do not normally bundle these code combinations, nor do the codes have “separate procedure” designations.
- 25. Ob-gyn Case Study 1Ob-gyn Case Study 1 One of your ob-gyn’s regular patients is having twins, and your ob- gyn delivers them both vaginally. Two deliveries, however, do not mean you should submit two global ob codes. Reality: You should report the global code (59400) for the first baby and 59409-51 (Vag inalde live ry o nly [with o r witho ut e pisio to m y and/o r fo rce ps]; Multiple pro ce dure s ) for the second. Heads up: You should know your payer’s preferences. Some insurance companies instead prefer that you bill the additional delivery with modifier 59 (Distinct pro ce duralse rvice ) attached. Other payers will not pay anything additional for twin B when the delivery is vaginal.
- 26. Ob-gyn Case Study 2Ob-gyn Case Study 2 You can report the tubal ligations following a vaginal delivery (59400, 59409, 59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 with modifier 59 (Distinct pro ce duralse rvice ) appended. Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery, even though they occurred during the same session. Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.
- 27. Ob-gyn Case Study 2Ob-gyn Case Study 2 Watch out: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the ob-gyn has already done the prep work for the patient prior to delivery and therefore, payers don’t need to pay twice for the same work. In other words, they treat it just like any other multiple procedure. If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unre late d pro ce dure o r se rvice by the sam e physician during the po sto pe rative pe rio d). You should receive full reimbursement for the procedure.
- 28. Separate SessionSeparate Session Payers may be looking for evidence that the separate procedure was done during a separate encounter. Ex. A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported 44140 and then reported 49561 with modifier 59. The payer denied the claim. Were we wrong to append modifier 59? Answer: You might think modifier 59 would be appropriate for the hernia code and that you could bill it separately. But 59 tells the payer the hernia repair occurred during a separate session, which isn’t true in this case. Modifier 22 (Incre ase d pro ce duralse rvice s ) could apply here, provided you can support that extra work was done. Mary Compton, PhD, CPC
- 29. Lookto OtherModifiersLookto OtherModifiers Rule #3: If a more specific modifier describes the situation, you should not use modifier 59. Modifier 59 “should be the modifierof last resort and only used when there is no other modifier to compliantly bypass the bundling edit and the procedure was clearly distinct and different from that of the other procedure.” ---Suzan Berman, CPC, CEMC, CEDC Senior manager of coding and compliance UPMC departments of Surgery and Anesthesiology.
- 30. Payment Reduction QuandaryPayment Reduction Quandary Scenario: The physician removes one lesion and biopsies another. Medicare pays the removal at 100 percent and the biopsy at 50 percent. The carrier applies this payment reduction even though you use modifier 59 on the bundled procedure -- the biopsy. Your dilemma: Should you find an alternative way to code encounters like this so that you can avoid the fee reduction?
- 31. Payment Reduction SolutionPayment Reduction Solution The answer: Normally, a lesion removal includes a biopsy. To indicate that the biopsy occurred at a separate site from the lesion removal -- and thus deserves separate payment -- you must append modifier 59 to the otherwise bundled biopsy code. Don’t miss: Although same-session, separate-site lesion removals and biopsies deserve separate payment, modifier 59 does not exempt the claim from multiple-procedure payment rule reductions, which you probably associate with modifier 51 (Multiple pro ce dure s ).
- 32. The list of code combinations requiring supporting documentation was reduced by approximately 25%, beginning May 17, 2010. Supporting documentation continues to be required on 79 code combinations, approximately 1% of claims submitted with a modifier 59. This update represents a significant reduction in the number of edits requiring documentation for dermatology services. The code pair list is available online with the Modifier 59 policy Guideline GuidanceGuideline Guidance CIGNA : Modifier59 Policy Supporting Documentation (UPDATE) So urce : CIGNA’s Network News, July 20 1 0
- 33. ResourcesResources • CIGNA’s Network News, July 2 0 1 0 , Modifier 59 policy (www.cignaforhcp.com> Resources > Clinical Reimbursement Policies and Payment Policies >Modifiers and Reimbursement Policies) • CPT 2010 Professional Edition, AMA, Jan. 1, 2010 ICD-9-CM CD-ROM. Ninth Version. Centers for Disease Control & Prevention and the National Center for Health Statistics. Oct. 1, 2010 Medicare Physician Fee Schedule, CMS, Oct. 1, 2010 • National Correct Coding Initiative, version 16.3, CMS, Oct. 1, 2010, https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage • United HealthCare, “CCI Editing Policy,” 2008R0105A, Dec. 9, 2009, http://www.littleurl.net/ec2e41
- 34. Save the Date!Save the Date! What Happened at AMA The sco o p fro m the CPT® and RBRVS 20 1 1 AnnualSym po sium witho ut the e xpe nse ! FREE Webinar Tuesday, Nov 23 12:00 pm EST Speaker: Jen Godreau, BA, CPC, CPEDC • Observation coding changes • You can recoup multiple vaccine components Registerat: www.SuperCoder.c om/conference Registerat: www.SuperCoder.c om/conference
- 36. Ensuring reimbursement. Insuring coders.Ensuring reimbursement. Insuring coders. Questions: www.supercoder.com/forum/ Mary Compton, Editorial Director Neurosurgery Jen Godreau, Content Director, Supercoder.com Family Practice, Pediatrics, Otolaryngology Suzanne Leder, Executive Editor Ob-Gyn , Orthopedics