CPT Coding Tutorial — Use of Modifier 59

CPT Coding Tutorial — Use of Modifier 59 https://www.cco.us/ceu-on-demand-classes-modifiers-yt

Laureen: Next question, modifier-59. This is one of our favorites, it keeps popping itself up.

Q: “Hi, can you talk about modifier-59 a bit. I seem to be one of those that overuse it. I have gotten a few questions wrong by adding it. I have the modifier download,” she is talking about our free giveaway “it is very helpful. Maybe a couple of examples of when it is appropriate to use and when it is not, so I can see the difference. And you always have tips that are easy to remember. Thanks so much.”

A: So, this is some information I pulled. A lot of times, when you’re trying to research questions for yourself, it’s good to go to the most respected sources. So, CMS is a pretty respected source. They have this Medicare Claims Processing Manual. All this is available online. And we have talked about in previous webinars how to do searches and things like that.

So, I found this information, it’s in Chapter 23 under Section 20.9.1.1B. It’s a government, what do you expect? It says: “59 is used to indicate a distinct procedure that could be performed in the same encounter or different encounters.” An example that I use in teaching is, from my own experience, unfortunately. I had an oophorectomy (as in ovary removal). It was an emergency one, they removed it, bring me back to the room. And my vitals went funny and they had to do an exploratory lap, to see what was going on and to stop some bleeding that was going on.

Normally, the laparotomy is bundled in to the oophorectomy because it wasn’t a scope procedure, it was an open procedure. As you may know, the approach to a surgical procedure is always bundled in. You don’t code opening them up and then code removing whatever it is and then code closing them up, it’s a bundled situation.

Now, in my case because I had to be brought back to the OR and they had to open me back up, they really did two laparotomies. So, in that case, they would bill the second laparotomy separately. But if a payer saw a laparotomy and an oophorectomy they think “They don’t know what they’re doing, these two codes are bundled. We’re not paying for the 49000 (the laparotomy).” But we as coders, if we put modifier-59 that’s our way of telling the payer that this looks bundled, but it’s not. This is done in a separate time in this case. Same date of service, but different time of day. OK? That’s just one example.

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