Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not at all sure when to use it. Other practices hesitantly apply it when they believe it is appropriate, and a few practices tack it on to all sorts of codes in the hopes it will result in a payment rather than a denial. This diversity in modifier usage is not surprising because Medicare’s modifier -59 directives are definitely vague.
CPT® Guidelines indicate that the modifier is to be used to show that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, a different procedure or surgery, a different site or organ system, or a separate incision/excision.
The trouble with this modifier -59 directive is that it is somewhat ambiguous, and as we work with different practices in improving their revenues and compliance, we have found that there is a wide variation in interpretation of directives. The definition refers to “different anatomic sites” and “separate patient encounters.” From an NCCI perspective, the anatomic sites include different organs or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ.
Medicare also advises that the use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosis code for each procedure. And the use of different diagnoses on the procedures does not necessarily support the use of modifier -59.
Correct use of modifier -59 is important because that modifier has the ability to over ride NCCI edits. NCCI edits define when two CPT® codes can be reported together and still be paid separately. If the NCCI edits show that two codes reported together cannot be paid separately, one of the codes will be denied – and the practice will not be paid for that service. However, when modifier-59 is attached to one of the codes, then both codes are likely to be paid. And as we are all aware, if Medicare pays us when they should not have paid us, then at some point in time they will take that money back. No one wants to pay money back, especially if we believed that we were due the money in the first place.
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ...
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.
The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI).
The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms.
ICD-10-CM Official Coding Guidelines - ...
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
Risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology based on the diagnoses of the individuals in that population. As payers move to value based models, they heavily rely on risk adjustment to ensure proper funding.
All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.