Nancy Posted Mon 22nd of February, 2010 15:24:45 PM
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
Melanie Answered Mon 22nd of February, 2010 15:35:36 PM
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
Documentation must support:
-a different session
-different procedure or surgery
-different site or organ system
-separate incision or excision
-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.
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
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
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
SuperCoder Answered Mon 22nd of February, 2010 16:59:27 PM
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.
Nancy Posted Mon 22nd of February, 2010 18:13:11 PM
They were all done on the same day.
SuperCoder Answered Wed 24th of February, 2010 14:28:41 PM
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.
SuperCoder Answered Wed 03rd of November, 2010 17:38:48 PM
Should I use a 51 or 59 modifier to Medicare for codes 21933 & 24073 when billed on the same claim.