FAQs

Q: We are looking for clarification on the use of modifier 59 when tangential biopsies (CPT 11102, 11103) are done on the same encounter as premalignant destructions (CPT 17000, 17003). Which code(s) should be appended with a -59 modifier? Can you provide clarification please?

A: Per NCCI Procedure-to-Procedure (PTP) Edits, Modifier 59, distinct procedural service, should be appended to code 17000, as it is paired with 11102 No modifier is needed for CPT codes 11103 and 17003. As of July of this year the NCCI and Medicare have indicated that a modifier may be appended to either of two paired codes. Conse-quently, for Medicare patients modifier -59 may be appended to either CPT 11102 or 17000.

Q: How do I apply modifier 59 if I perform more than 2 procedures on the same day? I know to look up procedure A and B in the NCCI edit columns to determine if a modifier is needed. When a third variable is added, do I compare B and C, or A and C?

A: All six procedure codes must be compared using the NCCI PTP listing in Medicare’s website under PTP edits. Procedure A, B, and C will all have to be checked against each other. The result: multiple codes may require a modifier.

Q: We have had some recent denials for symptomatic lipoma removals despite a prior authorization check with insurer for coverage.

A: According to the Medicare Physician Fee Schedule (MPFS), some procedures are consid-ered rarely or never performed in a non-facility setting. As such, some of the soft tissue exci-sion and biopsy codes may be denied based on site of service when the service has been delivered in a non-facility setting.