1. Nancy Smith
   Member
   Posted 6 months ago #
   

   When is it appropriate to add a 59 modifier on the cpt code 94150? Whenever we bill this cpt code with 96401, 94640 & J2357 we get a denial as inclusive even though the CCI edits show no bundling. Thank You

2. Melanie Cramer
   Member
   Posted 6 months ago #
   

   Here is the official Medicare-ism on Mod 59

   "NATIONAL CORRECT CODING INITIATIVE (NCCI)
   CMS developed the National Correct Coding Initiative (also referred to as CCI) to promote
   national correct coding methodologies and to control improper coding leading to inappropriate
   payment in Part B claims. CCI edits are pairs of CPT or HCPCS Level II codes that are not
   separately payable under certain circumstances. The edits are applied to services billed by the
   same provider for the same beneficiary on the same date of service. All claims are processed
   against CCI tables.
   -59 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 or 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 or excision
   -separate lesion
   -separate injury (or area of injury in extensive injuries)
   not normally encountered on the same day by the same individual. However, when
   another already established modifier is appropriate it should be used rather than modifier
   59. Only if no more descriptive modifier is available, and the use of modifier 59 best
   explains the circumstances should modifier 59 be used.
   Modifiers Billing Guide
   _________________________________________________________________________
   NHIC, Corp. 33 June 2009
   REF-EDO-0058 Version 3.0 06/12/09
   Message for internal use only: The master copy of this document is stored in the NHIC ISO Documentation Repository. Any other copy, either electronic or paper, is an uncontrolled copy and
   must be deleted or destroyed when it has served its purpose.
   Billing Tips:
   o Modifier -59 is an important National Correct Coding Initiative (NCCI) associated modifier
   that is often used incorrectly.
   o For the NCCI, the primary purpose of Modifier -59 is to indicate that two or more
   procedures are performed at different anatomic sites or during different patient encounters.
   o Before submitting this modifier, it is important to verify whether the services are bundled
   through NCCI. NCCI edits are updated quarterly and may be accessed at
   http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage.
   o Modifier -59 should not be used to bypass an NCCI edit, unless the proper criteria for use
   of the modifier is met and fully documented in the medical records.
   o Modifier -59 is used only on the procedure which is designated as the distinct procedural
   service.
   o Modifier -59 is used only if another modifier does not describe the situation more
   accurately or when its use best explains the circumstances. (See the additional modifiers
   listed in this section.)
   o No special documentation need be submitted with the claim when modifier -59 is used.
   o In all cases, documentation must be maintained in the patient’s medical records to support
   the use of modifier -59 and must be made available upon request.
   o Modifier -59 should not be used with an E/M service. To report a separate and distinct
   E/M service with a non-E/M service performed on the same date, see modifier 25.
   o Procedure codes"

   This is found at http://www.medicarenhic.com/providers/pubs/Modifiers%20Guide.pdf on page 32

3. apoorba ganguly
   Member
   Posted 6 months ago #
   

   Is it like all the 3 procedures (96401, 94640, 94150) were performed simultaneously, at the same session? Or were they performed in different time on the same day? You are absolutely correct in saying that CCI does not bundle any of the services. Still, many payers and MAC policies will not pay for a procedure, citing the reason that it is covered by another related and more extensive procedure. Therefore, to use modifier 59, we need to be very much accurate and document-specific and the document must support the medical necessity for another separate inhalation test like Vital capacity (94150) beside already performing the 94640.

   If posible, let us know the procedure scenario into more detail.

4. Nancy Smith
   Member
   Posted 6 months ago #
   

   They were all done on the same day.

5. apoorba ganguly
   Member
   Posted 6 months ago #
   

   The code 94150 is described as "separate procedure" at its descriptor. CPT “separate procedure” designation means that the Px is an “integral component” of other procedures at that site. I guess that the payer is declining to accept 94150 as a separately payable service because 94640 is already being provided on the same site, same day. Unless you submit a strong supporting documentation to show why performing the 94150 on the same day (may be at the same time) was absolutely necessary, there is less chance of payment for that.

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