Whether or not you have a solid understanding of the National Correct Coding Initiative (NCCI) edits, you are likely very familiar with modifier 59 and the X modifiers, which allow you to report two procedures at the same time. What many practices don’t know, however, is that payers are waiting for you to misuse these modifiers. There are a lot of rules governing appropriate application of them, and if you append them to the wrong code pairs, you can expect swift denials.
To ensure that you’re using modifier 59 and the X modifiers appropriately, check out these do’s and don’ts about them.
Do Check Whether Services Are Usually Performed Together
You can only use modifier 59 or the X modifiers if the provider performed two procedures together that aren’t ordinarily performed together or encountered on the same day. If one procedure is required to perform another, they will usually be bundled together under the NCCI edits.
Therefore, your first step is to consult the NCCI edits and see if the codes are bundled. If they are bundled and no modifier can separate the edits, then you won’t be able to submit a claim for both codes, even if you use modifier 59 or the X modifiers. But if they aren’t bundled—or a modifier can separate the edits—you may be able to use a modifier.
Do Refer to the Bundle Indicator
In the NCCI edits, look for a modifier indicator of “1” to evaluate whether the bundles can be separated under certain circumstances. Of course, just because the indicator is “1” doesn’t necessarily mean you’re justified in using a modifier, but it’s an important first step, telling you that payers may consider paying both when submitted together.
Do Evaluate Whether Different Sites/Sessions Apply
You can use modifier 59 or one of the X if different anatomic sites are addressed during the same session, different providers performed them, or you saw the patient during separate sessions. For instance, suppose the surgeon performed one procedure on the leg and another on the arm—this may warrant modifier XS or a modifier 59. Remember that the documentation must clearly note which organs or sites were addressed with each service so you can justify your modifier use.
Do Check Whether Other Modifiers Are More Appropriate
Modifier 59 is known as the “modifier of last resort” for a reason. You can only use modifier 59 or an X modifier if no other modifier describes the relationship between the two codes you’re trying to bill together. That may be modifier 25, RT, 58 or many others, depending on the circumstances.
Don’t Use 59 With E/M Codes
If you perform a procedure with an E/M code, then another modifier (usually modifier 25) is a better choice than modifier 59. Modifier 59 should only be used when you report two procedures together, and not a procedure and an office visit.
Don’t Stress About Separate Diagnoses
Contrary to popular belief, you need not have separate diagnoses to justify using modifier 59 or the X modifiers. If the doctor does address two separate conditions with the different procedures, you should certainly document them and report them on the claim form, but if you don’t have different diagnoses, that doesn’t necessarily mean your modifier 59 claims will be denied.
There are a lot more facts about modifier 59 that you must know to avoid auditor scrutiny. Let physician and practice management expert Dr. Dreama Sloan-Kelly walk you through the must-know strategies for using this modifier during her one-hour online training, Modifier 59: Proven Strategies to Boost Pay and Halt Denials. Sign up today!
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