By Dirk Elston, MD, June 01, 2011
I’ve read that modifier 59 is being audited. Is this true? Do I need to worry?
The Office of the Inspector General (OIG) reported that 40 percent of code pairs billed with modifier 59 in fiscal year 2003 did not meet Medicare requirements, resulting in $59 million in improper payments. The OIG report recommended that Medicare carriers provide instruction and monitor the use of modifier 59. Dermatologists should be aware of how to use the modifier correctly, as our patients often present with multiple distinct lesions that require treatment on the same day. We need to use modifier 59 to override the Correct Coding Initiative (CCI) edit that might otherwise bundle procedures reported on the same date of service and prevent proper payment.
When used properly, modifier 59 ensures appropriate payment for distinct and independent services performed by the same provider on a single date of service. The procedures usually involve distinct anatomic lesions, but could also represent a different patient encounter on the same day.
Note that modifier 59 is only used in conjunction with procedures, never with evaluation and management codes. Also note that modifier 59 should only be used for procedures designated as mutually exclusive or where Medicare recognizes one code as a component of the other code (e.g., Column 1 Code/Column 2 Code 17000/11100). It may be helpful to review last month’s article on CCI edits or the Correct Coding Initiative (CCI) Edits Manual, which is available at no cost through the CMS website at www.cms.hhs.gov/NationalCorrectCodInitEd/.[pagebreak]
Examples of the proper use and misuse of modifier 59:
Example 1: Use modifier 59
You excise a presumed melanoma and also biopsy a presumed basal cell on the same day. Append modifier 59 to the biopsy code to indicate that the procedures were performed on two distinct lesions.
Example 2: Do not use modifier 59
You sample a portion of a suspected basal cell carcinoma by means of shave technique, curette the base of the lesion, and send the specimen to the lab. This was a single lesion, so it would be inappropriate to report shave, biopsy, and destruction of the same lesion.
In order to receive the full reimbursement for the medically necessary services you provided, wait until the pathology report is received. If the report confirms that the lesion was a basal cell carcinoma, report only destruction of the malignant lesion. The correct diameter to report is the final diameter of the curettage defect.
If, on the other hand, the report confirms that this was merely a pearly benign melanocytic nevus, report only the biopsy as this was the medically necessary service. As your intent was to sample a portion of the lesion, you should use the skin biopsy code rather than a shave code. Shave codes are used when your intent is removal of the lesion while remaining in the dermis.
Example 3: Use modifier 59
When wart and actinic keratosis (AK) destruction are performed on the same day by the same provider on the same patient, the wart is a benign lesion while the AK is a premalignant lesion. Specific CPT codes are used to report the destruction procedures with modifier 59 appended to the AK destruction code to indicate that the service was performed on a separate distinct lesion during the same encounter, e.g. 17110 and 17000/59.
Common modifier 59 dermatologic coding sets
Examples of common modifier 59 dermatologic coding sets — assuming procedures are performed on separate lesions and/or sites — include:
17110/59 and 17311;
17110/59 and 17004;
11301/59 and 11200;
17261/59 and 17110;
11641/59 and 14040.