When modifier 59 is not enough part two | aad.org
When modifier 59 is not enough, part two

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, Calif., represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

Bookmark and Share

Coding correctly for covered services, avoiding billing for excluded services

Part one of this column offered the following vignette:

A Medicare patient visits you for the second time in the calendar year, this time with complaints of growing, occasionally bleeding facial lesions. You identify scattered keratotic actinic keratoses as well as probable basal cell carcinomas located on the cheek and nose. You destroy five actinic keratoses with liquid nitrogen and biopsy both suspected basal cell carcinomas. Your office then bills for two biopsies, CPT codes 11100 and 11101, and for the actinic keratoses destruction, CPT code 17000-59 and 17003-59x4.

Will the CPT codes, if presented as listed to the insurer, lead to a reimbursement? Billing for multiple procedures engenders several challenges:

  • Are all of the billed codes payable?
  • Which codes are to be billed as primary codes, and which will require a modifier?
  • Which modifier(s) should be used, and in what sequence?

As long as the services rendered are medically reasonable and necessary, then payment should be expected from the insurer. However, the trick is in presenting the billing with an appropriate sequence of modifiers in order to be paid. One would assume that just attaching a 59 modifier, indicating a distinct procedural service, should suffice. It is not that simple.


General guidelines for use and definitions of Level I and Level II modifiers are published in the AMA CPT manual, Appendix A. For multiple procedures done on the same day, a 59 modifier is typically attached to the secondary codes. Which of paired codes are primary, and which are secondary? In order to determine which code gets the 59 modifier, and indeed, whether two paired codes even qualify to be paid, one must consult the National Correct Coding Initiative (NCCI), which is a list developed by the Centers for Medicare and Medicaid Services (CMS).

The NCCI, accessible at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html, lists code pairs that ordinarily should not be billed together unless both reflect medically appropriate services. Three columns in the NCCI are of greatest importance for determining the appropriateness and placement of a modifier: column one, column two, and the last column. Column one lists the primary code, which does not require a modifier. Column two lists the code that will require an appropriate modifier. The last column contains a number 0, 1, or 9. Zero means that a column two service is never payable with column 1. A “1” indicates that a column two service is payable when an appropriate modifier is used. A “9” indicates that a previous NCCI edit for a code pair was deleted. [pagebreak]

Applying the NCCI edits table to this article’s clinical vignette, one finds that there is no NCCI column one 11100 biopsy code paired with a column two 17000 destruction code. However, there is a pairing of 17000 in column one with 11100 in column two, with a last column indicator of “1”.

This indicates that, with appropriate modifier selection and placement, both 17000 and 11100 are payable, and that the 11000 code should receive the 59 modifier, since it is listed in column two.

This all may seem somewhat convolutedly complicated. CMS has sought to clarify the arcane aspects of the NCCI with a January 2013 Medicare Learning Network article, “How to Use the Medicare National Correct Coding Initiative (NCCI) Tools.” This publication, downloadable at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf, is essential reading for those who assign billing, whether they be health professionals, coders, billers, or billing software programmers.

Now, let’s return to this article’s vignette. Utilizing the NCCI table one finds that 17000 does not require a modifier, as it is the column one code. 17003 is an add-on code that also requires no modifier. As 11100 appears in column two, it is assigned a 59 modifier. 11101 is not paired with any of the codes, as it is secondary to 11100. So, it does not require a modifier.

Following this logic, your office would usually bill the following: 17000, 17003x4, 11100-59, and 11101. This type of billing should ordinarily suffice for private insurers. [pagebreak]

However, as of July 1 of this year CMS issued a national directive aimed at ferreting out inappropriate duplicate billing that has resulted in payment denials for legitimately done multiple procedures. This has happened because CMS specifies that two procedures may be billed separately if they are performed at “different anatomic sites.” (See MLN Matters SE0715, available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0715.pdf, for details, and check with your Medicare carrier for its policy.)

It so happens that in dermatology, one may do multiple procedures that of necessity are billed with the same ICD-9-CM diagnosis code. For example, this article’s vignette lists separate biopsies done on the cheek and the nose. The ICD-9 code for each is the same: 173.31 Basal cell carcinoma of skin of other and unspecified parts of face. As the diagnosis code is identical for the two lesions, your Medicare contractor is likely to reject the second biopsy claim as a duplicate on the basis of same anatomical site location. Although it does not make inherent sense, adding a 76 modifier (“Repeat procedure or service by same physician or other qualified health professional”) to the secondary code, 11101, is likely to make this service payable. However, the NCCI does not recognize 76 modifiers as valid edit bypass modifiers, so the claim may still be rejected. Billing the service with a 59-76 modifier pair is likely to result in payment. [pagebreak]

Example 1: You incise, drain, curette out contents, and then excise an abscessed 2.5 cm diameter epidermoid cyst located on the back. You bill 11403 for the excision and 10061-59 for the complicated incision and drainage.

Answer: Incorrect. The primary procedure is the excision, and the incision and drainage of the abscess is considered incidental to the excision. Only 11403, benign excision, is billable.

Example 2: You curette and electrodesiccate a 0.8 cm basal cell carcinoma on the leg and freeze three actinic keratoses with liquid nitrogen. You bill 17000 and 17003x2 for the freezing along with 17261-59 for the basal cell carcinoma destruction.

Answer: Correct. An inspection of the NCCI table reveals that 17000 is listed in column one and 17261 is paired in column two. Consequently, the 17261 receives the modifier.

Example 3: You destroy a cheek basal cell carcinoma via curetting and electrodesiccation to a 1.1 cm diameter. After evaluating the depth of curetting you decide that it would be best therapeutically and cosmetically to excise the site with margins and suture the defect linearly. The excised defect measured 1.5 cm in diameter. After consulting the NCCI table you bill 17282 for the destruction and 11642-59 for the excision and single layer closure.

Answer: Incorrect. Only the final procedure done to complete the treatment is billable when the lesion removal method is changed during the course of the patient encounter. CPT 11642 is the appropriate code.