Beware of poor coding habits — Modifier 59 is not the secret ingredient
Derm Coding Consult
By Cynthia Stewart, CPC, CPMA, COC, CPC-I, Manager, Coding Education Content Expert, September 1, 2022
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.
Often, providing high-quality and timely patient care requires that a dermatologist perform multiple procedures or services during a single encounter. Consequently, one of the most often-used modifiers when reporting multiple dermatologic procedures or services is modifier 59. Modifier 59 is reported under certain circumstances to indicate that a procedure or service was distinct or independent from other procedural services performed on the same day, by the same dermatologist. 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 circumstance, such as a different anatomic site, separate incision or excision, separate lesion, or separate injury.
Known as a National Correct Coding Initiative (NCCI) edit modifier, modifier 59 is commonly used to identify when procedures or services, typically bundled by the NCCI procedure-to-procedure (PTP) edits, should be reported and adjudicated separately. Reporting modifier 59 will affect the adjudication of the reported code by overriding the payer’s incidental or mutually exclusive bundling edits, allowing the service or procedure eligibility for separate reimbursement.
Modifier help
For more information on modifier 59 and other modifiers, visit the AADA Practice Management website.
The NCCI edits were created to prevent inappropriate billing, including the billing of lesions and sites that are not considered separate and distinct. Regrettably, CMS has noted that modifier 59, while an important NCCI PTP-associated modifier, is often used incorrectly. As modifier 59 can be an audit trigger, it should not be appended to inappropriately bypass NCCI edits for a service or procedure when it is a component of or incidental to the primary procedure reported.
Appropriate reporting of modifier 59 can be tricky. Let’s take a look at the following claim example.
During an encounter, the dermatologist performed a tangential biopsy of the skin and destruction by electrosurgery of the same lesion. After reviewing the NCCI edits to determine if the two procedures are considered incidental to each other and if a modifier is needed to allow for adjudication of each, the procedures are reported as 11102 and 17000-59. A careful review of the medical record will determine if appending the modifier is correct and appropriate.
Although the reporting of this code pair with modifier 59 will result in the claim bypassing the payer’s claim editing system, the medical record of the encounter must satisfy the required criteria for reporting these as distinct procedural services. If upon review of the medical record, it is determined that the skin biopsy and destruction were performed for the same lesion, the NCCI edit, based on the CPT or CMS manual coding instructions, indicates that the skin biopsy is considered incidental to the destruction performed. In this case, only the destruction is reportable (CPT 17000) and modifier 59 should not be appended to this procedure.
However, if the skin biopsy and destruction were performed for separate lesions at different anatomic sites, the additional procedure may be appropriately reported with modifier 59 when another more descriptive modifier is not available.
Although modifier 59 is used to report distinct or independent procedures or services, it is considered the modifier of last resort. If another modifier is available that accurately explains the circumstance of the procedures or services, it should be used rather than modifier 59. Before appending modifier 59, consider if one of the anatomic modifiers more precisely reflects the circumstances of the encounter than modifier 59.
Anatomic modifiers – RT (right), LT (left), E1-4 (eyelids), FA-9 (fingers), and TA-9 (toes)
Anatomic modifiers can be reported with procedures that are performed at different anatomic regions, or in limited situations on different, non-contiguous lesions in different locations of the body.
If you did the procedures on different sides of the body, use modifiers RT and LT or another pair of anatomic modifiers.
Report modifier 59 with either procedure or service if they were done at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable.
For example, separate lesions treated on the left forearm and left upper arm should not be reported with modifier LT. In this case, modifier 59 would provide more information regarding the circumstances of the procedure, as the anatomic modifier LT would only reflect that the lesions were on the left side of the body, not that they were two distinct anatomic sites and thus two separate lesions.
For more information on the use and reporting of modifier 59 and other modifiers, visit the AADA Practice Management website.
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