Sunday, January 11, 2015

Other specific appropriate uses of modifier 59


There are three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter.

a. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.

There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other(i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.(See example below)

Example : Column 1 Code/Column 2 Code - 97140/97530

>CPT Code 97140 – Manual therapytechniques (eg, mobilization/manipulation, manually mphatic drainage, manual traction), one or more regions, each 15 minutes

>CPT Code 97530 –Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Modifier 59may be reported if the two procedures are performed in distinctly different 15 minute intervals.

CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same 15 minute time interval.

b.Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention;(b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and(c) it does not constitute a service that would have otherwise been required during the therapeutic intervention.(See example below)If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

Example : Column 1 Code / Column 2 Code - 37220/75710

>CPT Code 37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

>CPT Code 75710 – Angiography, extremity, unilateral, radiological supervision and interpretation Modifier 59 may be reported with CPT code 75710 if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery.

c. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.

When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example below)If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of modifier 59 does not require a different diagnosis for each CPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Example : Column 1 Code / Column 2 Code – 32551/71020

>CPT Code 32551 – Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open

>CPT Code 71020 – Radiologic examination, chest, 2 views, frontal and lateral Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. CPT code 71020 should not be reported and modifier 59 should not be used for a chest x-ray that is performed
following insertion of a chest tube in order to verify correct placement of the
tube.



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