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59 modifier on which procedure

Kimberly Posted Thu 19th of January, 2012 21:23:04 PM

What determines which procedure the 59 modifier is placed with? In this particular case, 45330 and 46930 performed at same sitting. Which would get the 59 modifier?

SuperCoder Answered Thu 19th of January, 2012 21:45:57 PM

Coding rules direct you to append modifier 51 (Multiple procedures) only when the physician completes multiple procedures during the same encounter, and to append modifier 59 (Distinct procedural service) only when the two procedures you want to submit are not normally submitted together but are appropriate under the circumstances. Modifier 59 is often used with code pairs that have an active bundling edit through the Correct Coding Initiative (CCI). Current CCI edits do not bundle codes 45330 and 46930 so I would recommend using modifier 51 (if your payer requires modifier 51 -- many payers, including Medicare, automatically append 51 and you don't need to add it).
You’ll probably find different opinions on whether to append modifier 51 or 59. Some coders opt for modifier 51 because most payers will process the encounter as a multiple surgical reduction whether you include the modifier or not. Other coders recommend modifier 59 because reporting modifier 51 could set you up for one of three undesirable (or at least aggravating) outcomes: the payer doesn’t reduce payment correctly; the payer denies the entire claim; or the payer requests additional documentation before considering payment. Of the two modifiers, modifier 51 is probably most appropriate in this instance.
However, coding rules state to only use modifier 59 if another more appropriate modifier isn't available. In this case, modifier 51 works so I would go with that.
If you select modifier 51, append it to the procedure with the lowest RVUs (relative value units) -- in this case, code 45330 with 4.20 RVUs (46930 has 6.10).
For future reference, if you determine that the physician performed distinctly separate procedures and CCI edits apply, append modifier 59 to the code listed in column 2 of the CCI edits.
I hope this helps.
Leesa A. Israel, BA, CPC, CUC, CMBS
Executive Editor, The Coding Institute
Manager, TCI Consulting & Revenue Cycle Solutions
Home office: (866) 458-2973

Kimberly Posted Thu 19th of January, 2012 22:03:03 PM

Wonderful--thanks so much!

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