The National Correct Coding Initiative (NCCI) maintains a list of procedures that are “bundled” and therefore cannot be billed at the same date and time. Many billers do not really understand importance of modifiers or when they need to be used. A modifier should never be used just to get higher reimbursement or to get paid for a procedure may bundle with another code. Modifiers are used to help communicate these unique circumstances and are necessary to bypass the NCCI edits. You should follow some steps before choosing modifier 59.
Modifier 59 is an important modifier and billers use it for a variety of circumstances; however, it is an understanding that to be applied incorrectly to bypass the NCCI edits.
Steps to Follow Before Choosing Modifier 59
- If your surgeons documentation shows you that a surgeon performed multiple procedures on the same patient on the same day then very first thing you should do is to check CCI edits for any bundled codes. While checking bundled codes take care of Centers for Medicaid and Medicare Services (CMS) guidelines.
- For codes with an indicator of “1,” agree if modifier 59 applies. The “distinct” in Distinct procedural service means the services which you want to unbundle were performed at a different anatomical site or organ system, while surgical session, incision, lesion, or injury.
- Next, consult any payer-specific guidelines. Modifier 59 should only be used if there is no other appropriate modifier—it’s the last resort. For example, LT, RT, and Medicare’s X modifiers (XS, XE, XP, and XU) offer more specificity than modifier 59. If a more appropriate modifier applies, use it instead.
- Consult any payer-specific guidelines before using modifier 59. Modifier 59 should only be used if there is no other appropriate modifier.
- If you have found that the modifier 59 is perfect fit, append it to the secondary procedural code.
According to the CCI edits, 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29820 (synovectomy, partial) are bundled with an indicator of “1.” Since the procedures were performed on a different anatomical site, they qualify as distinct procedural services.
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