Coding & Reimbursement

Clarifying Modifier 59

By Suzanne L. Corcoran, COE

From time to time, CMS publishes new instructions or clarifications about billing and coding. Recently, the agency issued a clarification on the use of modifier 59 that is important to ophthalmic practices.

Q. When is modifier 59 used?

CPT defines modifier 59 as distinct procedural service:

"Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier '59' is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances."

Modifier 59 is the "unbundling" modifier. It is used when the same physician performs two services, which would not otherwise occur together, at the same session. For Medicare, the National Correct Coding Initiative (NCCI) identifies services that are bundled or considered mutually exclusive with one another. Modifier 59 allows these services to be paid separately.

Q. What does the CMS clarification mean to us?

CMS determined that this modifier is frequently misused. An article recently published in Medlearn Matters (MLN), CMS' educational venue, clarifies the circumstances under which modifier 59 is appropriate. It specifically states that this is not a change, but only clarifies existing policy.

According to the MLN article, for NCCI edits "the primary purpose of modifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes."

Note that modifier 59 should be used only when two services occur on the same day, performed by the same physician, and constitute:

1. Different sessions or patient encounters, procedures or surgeries, or site/organ systems, or

2. Separate incisions or excisions, lesions or injuries.

Of key importance to ophthalmic practices is that the definition of different anatomic sites includes different organs or different lesions in the same organ. It does not include treatment of contiguous structures of the same organ. For example, as stated in Medlearn Matters, "Treatment of posterior segment structures in the eye constitutes a single anatomic site."

Ophthalmic practices have commonly used modifier 59 when different procedures were performed at the same anatomical site, especially when performed for different reasons. An example is planned anterior vitrectomy with cataract surgery following trauma to the eye. The article makes it clear that CMS does not consider this appropriate.

Modifier 59 has always been used cautiously and we expect further reduction in its use. We also expect that modifier 59 will be the subject of increased carrier scrutiny and audit.

You can access the complete MLN Matters article at: http://www.cms.hhs.gov/MLNMattersArticles/2007MMAN/list.asp #TopOfPage, article number SE0715.

Examples of Appropriate Use

The following are guidelines for using modifier 59:

■ A different procedure or surgery. Patient presents in the morning with cataract and angle closure glaucoma, and the surgeon performs a peripheral iridotomy (66761). By mid-day, the patient is not improving and the surgeon decides to remove the cataract immediately. He performs cataract extraction (6698x) later in the same day. Note that these two codes (66761, 6698x) are considered mutually exclusive under Medicare's NCCI edits.

■ A different site. Patient needs dilation/irrigation of punctum (68801) in the left eye and a nasal lacrimal duct probing (68810) in the right eye.

■ A separate lesion. The physician performs an intralesional injection (11900) to a lesion on the right upper eyelid nasally and excises (11440) a second distinct lesion on the right upper eyelid temporally. OM