Modifier 59-Break Bundles When You Should

1. MODIFIER59
BREAK BUNDLES WHEN YOU SHOULDBREAK BUNDLES WHEN YOU SHOULD
Jen Godreau, BA, CPC, CPEDC, Content DirectorJen Godreau, BA, CPC, CPEDC, Content Director
Mary Compton, PhD, CPC, Editorial DirectorMary Compton, PhD, CPC, Editorial Director
Suzanne Leder, BA, M.Phil, CPC, COBGC, Editorial ManagerSuzanne Leder, BA, M.Phil, CPC, COBGC, Editorial Manager
The Coding Institute, LLC . SuperCoder.comThe Coding Institute, LLC . SuperCoder.com

2. Are rats smarter than
humans?

3. Get Allowed Payment FasterGet Allowed Payment Faster
Goals
 Bust bundles
 Recognize allowed
boosters
 Use reducers when
necessary
Benefits
 Identify services that
are eligible for
separate payment
 Avoid dangerous
unbundling habits
 Stop wasting time on
unnecessary appeals

4. OIG 59 FindingsOIG 59 Findings
• 15% performed at same
session/site/incision
• Ex: chemotherapy, IV infusion
• 25% lacked supporting
service(s) documentation
• 11% used 59 on primary
code, instead of secondary
code
• 13% had 59 on both codes

5. Modifier59: The BundleModifier59: The Bundle
BreakerBreaker

6. CCI OriginsCCI Origins
 National Correct Coding Initiative (CCI)
 Created by Centers for Medicare and
Medicaid Services (CMS)
 Purpose: To apply CPT coding conventions
Sometimes does,
Sometimes doesn’t

7. CCI SystemCCI System
Column 1
Comprehensive
Column 2
ComponentIncludes
Critical care
99291
Pulse Ox
94760Includes

8. ExceptionsExceptions
 Some edits allow a modifier to override a
bundled pair
 Modifier Indicators:
 “0” — No modifier allowed
 “1” — Modifier allowed
Unusual circumstance must warrant
separate reimbursement
Unusual circumstance must warrant
separate reimbursement
“… Modifier 59 is used to
identify services/procedures,
other than E/M services, that
are not normally reported
together, but are appropriate
under the circumstances.”
So urce : CPT 20 0 9 Appe ndix A

9. Circumstance CriteriaCircumstance Criteria
Documentation must support a:
 different session
 different procedure or surgery
 different site or organ system
 separate incision/excision
 separate lesion
 separate injury (or area of injury in extensive injuries)
CPT 20 0 8 re vise d fro m “m ay re pre se nt” to “m ust
suppo rt”.

10. Alternative ‘Breaker’ ModifiersAlternative ‘Breaker’ Modifiers
United HealthCare (UHC) allows you to break a
bundle with these modifiers:
 58, 59, 78, 79, 91
 E1, E2, E3, E4
 LC, LD, LT, RC, RT
 TA, T1, T2, T3, T4, T5, T6, T7, T8, T9
 FA, F1, F2, F3, F4, F5, F6, F7, F8, F9
Nail avulsion (11730) on right ring finger and
evacuation of blood under nail (11740) on right
middle finger
Bundle breaker: 11730-F8, 11740-F7
Nail avulsion (11730) on right ring finger and
evacuation of blood under nail (11740) on right
middle finger
Bundle breaker: 11730-F8, 11740-F7
So urce : CCIEditing
Po licy

11. Reserve 59 for2 ProceduresReserve 59 for2 Procedures
 shows service or
procedure
separate from
E/M service
 1 service, 1
procedure
 shows procedure or
service distinct or
independent “from
other non-E/M
service performed
on the same day …”
 1 procedure, 1
procedure
Modifier 25 Modifier 59
So urce : CPT 20 0 9
Appe ndix A
CPT 2008
added
CPT 2008
added

12. Modifier59 RulesModifier59 Rules
1. Append to non-E/M codes only
2. Not normally reported together,
but appropriate under
circumstances
 Different site or location
1. No more descriptive modifier
applies

13. ECG, Unrelated ProcedureECG, Unrelated Procedure
CCI 15.1 bundled ECG
codes 93000-93010 into
 Wart removal (17110)
 In/out catheterization
(51701)
 Removal of impacted
cerumen (69210)
Use 59 on component code when different
reason
Use 59 on component code when different
reason

14. Test YourselfTest Yourself
 A patient comes into have a wart removed
(17110) and at the visit complains of chest
pain.
 To evaluate the patient’s chest pain, the
physician takes a history, performs an exam,
and as part of medical decision making orders
an in-office ECG to evaluate the patient’s
chest pain (ECG). The physician documents
his interpretation of the ECG reading as
revealing no heart-related problems. Should
you code the ECG?
Answer: A. Yes.
ECG is for a different reason than the
wart removal so you can report the
ECG.
• 9921x, 786.59 (Che st pain; o the r)
• 17110, 078.10 (Viralwarts,
unspe cifie d)
• 93000-59, 786.59
Answer: A. Yes.
ECG is for a different reason than the
wart removal so you can report the
ECG.
• 9921x, 786.59 (Che st pain; o the r)
• 17110, 078.10 (Viralwarts,
unspe cifie d)
• 93000-59, 786.59

15. Is InhalerEducation & TrainingIs InhalerEducation & Training
OK?OK?
Col 1 RVUs Col 2 RVUs
94640 0.38 94664 0.39
Inhalation treatment
Demonstration and/or
evaluation of patient
utilization of an aerosol
generator, nebulizer,
metered dose inhaler or
IPPB device

16. Is Training at SeparateIs Training at Separate
Session?Session?
 Code only treatment
 Occurs during treatment
 Staff/physician
shows steps while
patient receiving
treatment
 9921x(25), 94640
 Code treatment,
training
1. Patient receives
treatment
 Rescue medication
1. MD decides education
necessary
2. Staff does training
 Maintenance medication
 9921x(25), 94640, 94664-
59
No, occurs during treatment Yes, occurs aftertreatment

17. Combat Denials With AmmoCombat Denials With Ammo
“Typically, code 94640 does not include
patient education. If separate medication
instruction occurs on the same day as an
initial aerosol treatment (e . g . , a different
formof inhalerrequiring education), code
94664 can be used with a 59 modifier to
indicate the distinct procedural service.”
-- Steve G. Peters, MD, FCCP
“Continuous Bronchodilator Therapy,” Che st (2007; 131; 286-289)
published by the American College of Chest Physicians
Dept of IM, Div of Pulmonary & Critical Care Medicine at Mayo Clinic ~ Rochester, Minn.
Tool

18. Orthopedic Case Study 1Orthopedic Case Study 1
A 61-year-old male general contractor has been having severe left
shoulder pain for the last six months, which is now awakening him
from sleep. Physical therapy and nonsteroidal anti-inflammatories
(NSAIDS) have failed to resolve the problem.
The orthopedist’s physical exam demonstrates positive
impingement signs, with weakness on testing abduction and
external rotation. X-ray reveals a type 2 acromion and small cystic
changes in the greater tuberosity. MRI is positive for acromial
impingement on the rotator cuff and shows a small rotator cuff tear.
The orthopedic surgeon performs shoulder arthroscopy with
extensive debridement of an anterior and posterior labral tear. She
then enters the subacromial space and performs subacromial
decompression. She also performs distal clavicle resection and
debrides the rotator cuff, and then she switches to a mini-open
procedure and repairs the rotator cuff.

19. Orthopedic Case Study 1Orthopedic Case Study 1
A key point in the op report is that the surgeon began with an
arthroscopic debridement of the large labral tear. You should begin
with 29823 (Arthro sco py, sho ulde r, surg ical; de bride m e nt,
e xte nsive ), although you’ll need to append a modifier when you add
other codes. You should then address the open rotator cuff repair,
using 23412 (Re pair o f rupture d m usculo te ndino us cuff [e . g . , ro tato r
cuff] o pe n; chro nic).
How to decide between 23410 and 23412: If you choose 23410 (...
acute ) instead of 23412, you will gain about $60 more
reimbursement for this part of the surgery, but “acute” is not
appropriate in this case. He’s been having this pain for over six
months. “Acute” describes pain that began more recently, certainly
within the past six months.

20. Orthopedic Case Study 1Orthopedic Case Study 1
Now look to the arthroscopy codes. The next codes on your claim
should be 29824-51 (... distalclavicule cto m y including distal
articular surface [Mum fo rd pro ce dure ]; Multiple pro ce dure s ) and
29826-59 (... de co m pre ssio n o f subacro m ialspace with partial
acro m io plasty, with o r witho ut co raco acro m ialre le ase ; Distinct
pro ce duralse rvice ).
Why modifier51 and 59? The Correct Coding Initiative (CCI)
bundles 29826 into 23412, but you can override that edit in this
case with modifier 59. CCI does not bundle 29824 with 23412, so
you don’t need modifier 59 to override that edit. You simply need
modifier 51 to indicate multiple procedures. Keep in mind that some
payers’ software, such as with Medicare’s, automatically applies
modifier 51 for multiple procedure claims. Ask your payers whether
you need to use this modifier.

21. Orthopedic Case Study 1Orthopedic Case Study 1
Your final codes should look like this:
 23412 for the open rotator cuff repair
 29826-59 for the arthroscopic acromioplasty
 29824-51 for the arthroscopic distal clavicle
excision
 29823-59 for the arthroscopic extensive
debridement.

22. Orthopedic Case Study 2Orthopedic Case Study 2
A 21-year-old male who was struck by an automobile while riding
his bicycle presents to the ED with a serious crush injury to the left
lower extremity with massive swelling, ecchymosis, loss of
sensation in the foot, and tightness of all four lower leg
compartments and of the foot. He also complains of left elbow and
shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left
calcaneal fracture, left radial head fracture, and clavicle fracture.
The orthopedist admits the patient. The patient undergoes
immediate surgery to stabilize his fracture and treat his acute
compartment syndromes of the lower leg and foot. The surgery
involves a closed reduction of the tibial plateau fracture with
application of an external fixator. The orthopedist plans open
treatment of this fracture and the calcaneal fracture once the
patient’s fasciotomy wounds are closed.

23. Orthopedic Case Study 2Orthopedic Case Study 2
The code with the highest relative unit will be the code for the closed
treatment of the tibial fracture 27532-LT (Clo se d tre atm e nt o f tibialfracture ,
pro xim al(plate au); with o r witho ut m anipulatio n, with ske le taltractio n; Le ft
side ).
Next, report 20690-51-LT (Applicatio n o f a uniplane (pins o r wire s in o ne
plane ), unilate ral, e xte rnalfixatio n syste m ; Multiple pro ce dure s; Le ft side ).
After that, you should report the decompression leg fasciotomy code.
Depending on the compartments released, you would report 27600 for
anterior and lateral, 27601 for posterior only, or 27602 for anterior and/or
lateral and posterior. You’ll most likely report 27602, because the scenario
describes all four compartments as tight. Depending on insurer, you might
need modifier 51 on 27602. You can also apply modifier LT.
For the fasciotomy, you should report 28008-51 (Fascio to m y, fo o t and/o r
to e ).

24. Orthopedic Case Study 2Orthopedic Case Study 2
Question: Should you rule out adding modifier
59 to this claim?
Answer: Yes. Neither code has “separate procedure”
designation, and the combination isn’t normally bundled.
Adding modifier 59 to this claim is inappropriate because
payers following CCI edits do not normally bundle these
code combinations, nor do the codes have “separate
procedure” designations.
Answer: Yes. Neither code has “separate procedure”
designation, and the combination isn’t normally bundled.
Adding modifier 59 to this claim is inappropriate because
payers following CCI edits do not normally bundle these
code combinations, nor do the codes have “separate
procedure” designations.

25. Ob-gyn Case Study 1Ob-gyn Case Study 1
One of your ob-gyn’s regular patients is having twins, and your ob-
gyn delivers them both vaginally. Two deliveries, however, do not
mean you should submit two global ob codes.
Reality: You should report the global code (59400) for the first baby
and 59409-51 (Vag inalde live ry o nly [with o r witho ut e pisio to m y
and/o r fo rce ps]; Multiple pro ce dure s ) for the second.
Heads up: You should know your payer’s preferences. Some
insurance companies instead prefer that you bill the additional
delivery with modifier 59 (Distinct pro ce duralse rvice ) attached.
Other payers will not pay anything additional for twin B when the
delivery is vaginal.

26. Ob-gyn Case Study 2Ob-gyn Case Study 2
You can report the tubal ligations following a vaginal delivery
(59400, 59409, 59410). If the tubal ligation occurs immediately after
the delivery (during the same operative session), use 58605 with
modifier 59 (Distinct pro ce duralse rvice ) appended.
Remember: You should use modifier 59 to identify procedures that
are distinctly separate from any other procedure the physician
provides on the same date. In this case, modifier 59 tells the payer
the tubal ligation was a distinct service from the delivery, even
though they occurred during the same session.
Because the tubal ligation requires a separate incision and is
essentially unrelated to the vaginal delivery, carriers that pay for the
ligation under other circumstances will generally not take issue with
reimbursement using this coding sequence.

27. Ob-gyn Case Study 2Ob-gyn Case Study 2
Watch out: Some carriers may pay less for tubal ligation when
reported with modifier 59. Some policies reason that the ob-gyn has
already done the prep work for the patient prior to delivery and
therefore, payers don’t need to pay twice for the same work. In
other words, they treat it just like any other multiple procedure.
If the tubal ligation occurs a day or more after the delivery (during
the same hospital stay), use 58605 with modifier 79 (Unre late d
pro ce dure o r se rvice by the sam e physician during the
po sto pe rative pe rio d). You should receive full reimbursement for
the procedure.

28. Separate SessionSeparate Session
Payers may be looking for
evidence that the separate
procedure was done during a
separate encounter.
Ex. A patient presented for a
colectomy for colon cancer. The
physician also discovered that
the patient had a ventral
incarcerated hernia that required
a complex repair using mesh.
Because of the separate work,
we reported 44140 and then
reported 49561 with modifier 59.
The payer denied the claim.
Were we wrong to append
modifier 59?
Answer: You might think modifier
59 would be appropriate for the
hernia code and that you could
bill it separately. But 59 tells the
payer the hernia repair occurred
during a separate session, which
isn’t true in this case. Modifier 22
(Incre ase d pro ce duralse rvice s )
could apply here, provided you
can support that extra work was
done.
Mary Compton, PhD, CPC

29. Lookto OtherModifiersLookto OtherModifiers
 Rule #3: If a more specific modifier describes
the situation, you should not use modifier 59.
 Modifier 59 “should be the modifierof last
resort and only used when there is no other
modifier to compliantly bypass the bundling edit
and the procedure was clearly distinct and
different from that of the other procedure.”
---Suzan Berman, CPC, CEMC, CEDC
Senior manager of coding and compliance
UPMC departments of Surgery and Anesthesiology.

30. Payment Reduction QuandaryPayment Reduction Quandary
Scenario: The physician removes one lesion and biopsies
another. Medicare pays the removal at 100 percent and the biopsy
at 50 percent. The carrier applies this payment reduction even
though you use modifier 59 on the bundled procedure -- the biopsy.
Your dilemma: Should you find an alternative way to code
encounters like this so that you can avoid the fee reduction?

31. Payment Reduction SolutionPayment Reduction Solution
 The answer: Normally, a lesion removal includes a biopsy. To
indicate that the biopsy occurred at a separate site from the lesion
removal -- and thus deserves separate payment -- you must
append modifier 59 to the otherwise bundled biopsy code.
 Don’t miss: Although same-session, separate-site lesion removals
and biopsies deserve separate payment, modifier 59 does not
exempt the claim from multiple-procedure payment rule reductions,
which you probably associate with modifier 51 (Multiple
pro ce dure s ).

32.  The list of code combinations requiring supporting documentation
was reduced by approximately 25%, beginning May 17, 2010.
 Supporting documentation continues to be required on 79 code
combinations, approximately 1% of claims submitted with a modifier
59. This update represents a significant reduction in the number of
edits requiring documentation for dermatology services.
 The code pair list is available online with the Modifier 59 policy
Guideline GuidanceGuideline Guidance
CIGNA : Modifier59 Policy Supporting Documentation (UPDATE)
So urce : CIGNA’s Network News, July
20 1 0

33. ResourcesResources
• CIGNA’s Network News, July 2 0 1 0 , Modifier 59 policy (www.cignaforhcp.com> Resources >
Clinical Reimbursement Policies and Payment Policies >Modifiers and Reimbursement Policies)
• CPT 2010 Professional Edition, AMA, Jan. 1, 2010
 ICD-9-CM CD-ROM. Ninth Version. Centers for Disease Control & Prevention and the National Center
for Health Statistics. Oct. 1, 2010
 Medicare Physician Fee Schedule, CMS, Oct. 1, 2010
• National Correct Coding Initiative, version 16.3, CMS, Oct. 1, 2010,
https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage
• United HealthCare, “CCI Editing Policy,” 2008R0105A, Dec. 9, 2009, http://www.littleurl.net/ec2e41

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36. Ensuring reimbursement. Insuring coders.Ensuring reimbursement. Insuring coders.
Questions:
www.supercoder.com/forum/
Mary Compton, Editorial Director
Neurosurgery
Jen Godreau, Content Director, Supercoder.com
Family Practice, Pediatrics, Otolaryngology
Suzanne Leder, Executive Editor
Ob-Gyn , Orthopedics