Coding & Reimbursement
Unbundling Confusion
By Suzanne L. Corcoran, COE
This month we continue our discussion of modifiers. Modifier 59 is the "unbundling" modifier and much confusion and controversy continues about its appropriate use. I'll try to offer clarity below.
Q. How is modifier 59 defined in CPT?
Q. When is modifier 59 used?
A. When a procedure or service includes two or more CPT codes that are bundled in Medicare's National Correct Coding Initiative (NCCI) edits, yet circumstances support separate charges. It is not commonly used.
Q. Can this modifier be applied in conjunction with other modifiers?
A. Sometime, but not usually. The CPT definition states, "… when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used." An exception is made for the use of informational modifiers, such as RT (right eye) and LT (left eye).
Q. May you use modifier 59 to get around the NCCI edits if each procedure has a distinct indication and is preplanned?
A. No. According to Medicare's MLN Matters (No. SE0715): "Use of modifier 59 … does not require a different diagnosis for each HCPCS/CPT code procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters."
Q. Are different areas of the retina (e.g., macula and peripheral retina) considered different anatomic sites?
A. No. Medicare is quite specific about this: "The definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. … Treatment of posterior segment structures in the eye constitute a single anatomic site." OM
| Upcoming Seminars from Corcoran Consulting |
|---|
| If you'd like in-depth advice on billing and coding and live in or near one of the cities below, consider attending Corcoran Consulting's 2009 seminar series. Call 800-399-6565 for more information. Pittsburgh………………March 26 Los Angeles……………April 30 Atlanta…………………April 30 Louisville………………May 7 Philadelphia……………May 14 Denver…………………May 14 Detroit…………………May 21 Houston………………June 18 Chicago………………June 25 Charleston……………June 25 |
| Case Studies |
|---|
| Case #1: In your office in the morning, you examine a patient with uncontrolled open-angle glaucoma and perform gonioscopy at the same time. You schedule her for laser trabeculoplasty (LT) at the hospital later the same day. During LT, you use a gonio lens to perform the treatment. In the NCCI edits, 92020 is bundled with 65855. For the visit in the morning, you will bill for the visit (9xxxx) plus gonioscopy (92020). Because gonioscopy is bundled with LT, which is performed later the same day, Medicare would normally deny the claim for 92020 as bundled with the LT. However, you performed the gonioscopy during the visit in the morning, which is a separate session. This warrants the use of modifier 59 to separate the gonioscopy from the LT. Bill this as 92020-59. Case #2: The patient presents with central retinal vein occlusion in the left eye. You perform gonioscopy (92020) to check for rubeosis. On the same day, she has a suspicious-looking lesion on the right eyelid. You want a comparative photograph to check for progression at the next visit. You order an external photo (92285) of the lesion. In Medicare's NCCI edits, 92020 is bundled with 92285. Answer: The external photo (92285) is performed on the right eye, while the gonioscopy (92020) is performed on the left eye. Bill this as 92285-RT and 92020-59LT. You will probably also have an exam charge. Rationale: Different anatomical sites. |
| Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com. |
![]({"src":"/media/cwrbus23/32009.jpg","focalPoint":null,"crops":[{"alias":"thumbnail","width":1110,"height":700,"coordinates":null}]})