59 Modifier Medical Bill Confounds CMS
The 59 Modifier Medical Bill Controversy.A friend of mine forwarded a note on how medical bills could have be over-inflated by the use of what is known as a 59 modifier. Her company does not use that modifier.
According to Optum – a medical bill coding company, the Center for Medicare Services (CMS) instituted a new set of codes to combat this overcharging. From what I have read, the use of this modifier on certain medical bill charges was basically rampant.
For further reading, you may want to check out this guidance transmittal from the CMS. CMS estimated that the use of a 59 modifier cost them over $75 million in excess charges.
The modifier can also be used in Workers Comp. I could stand corrected, but I am under the impression that PPO Networks and bill review systems for WC would have not caught the overuse of this modifier.
According to CMS:
The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
This leads one to wonder how many overcharges were experienced in the Workers Comp arena.
CMS points out the main misuse of the 59 modifier.
Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different. One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.”
The code descriptors of the two codes of a code pair edit usually represent different procedures, even though they may be overlapping. The edit indicates that the two procedures should not be reported together if performed at the same anatomic site and same patient encounter as those procedures would not be considered to be “separate and distinct.”
The provider should not use modifier 59 for such an edit based on the two codes being “different procedures.” (See example 8) However, if the two procedures are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures on that date of service.
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