MODIFIER 59 BREAK BUNDLES WHEN YOU SHOULD

Transcription

1 MODIFIER 59 BREAK BUNDLES WHEN YOU SHOULD Jen Godreau, BA, CPC, CPEDC, Content Director Mary Compton, PhD, CPC, Editorial Director Suzanne Leder, BA, M.Phil, CPC, COBGC, Editorial Manager The Coding Institute, LLC. SuperCoder.com

2 Are rats smarter than humans?

3 Get Allowed Payment Faster Goals Bust bundles Recognize allowed boosters Use reducers when necessary Benefits Identify services that are eligible for separate payment Avoid dangerous unbundling habits Stop wasting time on unnecessary appeals

4 OIG 59 Findings 15% performed at same session/site/incision Ex: chemotherapy, IV infusion 25% lacked supporting service(s) documentation 11% used 59 on primary code, instead of secondary code 13% had 59 on both codes

5 Modifier 59: The Bundle Breaker

6 CCI Origins National Correct Coding Initiative (CCI) Created by Centers for Medicare and Medicaid Services (CMS) Purpose: To apply CPT coding conventions Sometimes does, Sometimes doesn t

7 CCI System Column 1 Comprehensive Includes Column 2 Component Critical care Includes Pulse Ox 94760

8 Exceptions Some edits allow a modifier to override a bundled pair Modifier Indicators: 0 No modifier allowed 1 Modifier allowed Modifier 59 is used to identify services/procedures, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Source: CPT 2009 Appendix A Unusual circumstance must warrant separate reimbursement

9 Circumstance Criteria Documentation must support a: different session different procedure or surgery different site or organ system separate incision/excision separate lesion separate injury (or area of injury in extensive injuries) CPT 2008 revised from may represent to must support. No longer examples.

10 Alternative Breaker Modifiers United HealthCare (UHC) allows you to break a bundle with these modifiers: 58, 59, 78, 79, 91 E1, E2, E3, E4 LC, LD, LT, RC, RT TA, T1, T2, T3, T4, T5, T6, T7, T8, T9 FA, F1, F2, F3, F4, F5, F6, F7, F8, F9 Source: CCI Editing Policy Nail avulsion (11730) on right ring finger and evacuation of blood under nail (11740) on right middle finger Bundle breaker: F8, F7

11 Reserve 59 for 2 Procedures Modifier 25 Modifier 59 shows service or procedure separate from E/M service 1 service, 1 procedure CPT 2008 added shows procedure or service distinct or independent from other non-e/m service performed on the same day 1 procedure, 1 procedure Source: CPT 2009 Appendix A

12 Modifier 59 Rules 1. Append to non-e/m codes only 2. Not normally reported together, but appropriate under circumstances Different site or location 3. No more descriptive modifier applies

13 ECG, Unrelated Procedure CCI 15.1 bundled ECG codes into Wart removal (17110) In/out catheterization (51701) Removal of impacted cerumen (69210) Use 59 on component code when different reason

14 Test Yourself A patient comes into have a wart removed (17110) and at the visit complains of chest pain. To evaluate the patient s chest pain, the physician takes a history, performs an exam, and as part of medical decision making orders an in-office ECG to evaluate the patient s chest pain (ECG). The physician documents his interpretation of the ECG Answer: A. Yes. reading as revealing no heart-related problems. Should you code the ECG? ECG is for a different reason than the wart removal so you can report the ECG. 9921x, (Chest pain; other) 17110, (Viral warts, unspecified) ,

15 Is Inhaler Education & Training OK? Col 1 RVUs Col 2 RVUs Inhalation treatment Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device

16 Is Training at Separate Session? No, occurs during treatment Code only treatment Occurs during treatment Staff/physician shows steps while patient receiving treatment 9921x(25), Yes, occurs after treatment Code treatment, training 1. Patient receives treatment Rescue medication 2. MD decides education necessary 3. Staff does training Maintenance medication 9921x(25), 94640,

17 Combat Denials With Ammo Typically, code does not include patient education. If separate medication instruction occurs on the same day as an initial aerosol treatment (e.g., a different form of inhaler requiring education), code can be used with a 59 modifier to indicate the distinct procedural service. Tool -- Steve G. Peters, MD, FCCP Continuous Bronchodilator Therapy, Chest (2007; 131; ) published by the American College of Chest Physicians Dept of IM, Div of Pulmonary & Critical Care Medicine at Mayo Clinic ~ Rochester, Minn.

18 Orthopedic Case Study 1 A 61-year-old male general contractor has been having severe left shoulder pain for the last six months, which is now awakening him from sleep. Physical therapy and nonsteroidal anti-inflammatories (NSAIDS) have failed to resolve the problem. The orthopedist s physical exam demonstrates positive impingement signs, with weakness on testing abduction and external rotation. X-ray reveals a type 2 acromion and small cystic changes in the greater tuberosity. MRI is positive for acromial impingement on the rotator cuff and shows a small rotator cuff tear. The orthopedic surgeon performs shoulder arthroscopy with extensive debridement of an anterior and posterior labral tear. She then enters the subacromial space and performs subacromial decompression. She also performs distal clavicle resection and debrides the rotator cuff, and then she switches to a mini-open procedure and repairs the rotator cuff.

19 Orthopedic Case Study 1 A key point in the op report is that the surgeon began with an arthroscopic debridement of the large labral tear. You should begin with (Arthroscopy, shoulder, surgical; debridement, extensive), although you ll need to append a modifier when you add other codes. You should then address the open rotator cuff repair, using (Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; chronic). How to decide between and 23412: If you choose (... acute) instead of 23412, you will gain about $60 more reimbursement for this part of the surgery, but acute is not appropriate in this case. He s been having this pain for over six months. Acute describes pain that began more recently, certainly within the past six months.

20 Orthopedic Case Study 1 Now look to the arthroscopy codes. The next codes on your claim should be (... distal claviculectomy including distal articular surface [Mumford procedure]; Multiple procedures) and (... decompression of subacromial space with partial acromioplasty, with or without coracoacromial release; Distinct procedural service). Why modifier 51 and 59? The Correct Coding Initiative (CCI) bundles into 23412, but you can override that edit in this case with modifier 59. CCI does not bundle with 23412, so you don t need modifier 59 to override that edit. You simply need modifier 51 to indicate multiple procedures. Keep in mind that some payers software, such as with Medicare s, automatically applies modifier 51 for multiple procedure claims. Ask your payers whether you need to use this modifier.

21 Orthopedic Case Study 1 Your final codes should look like this: for the open rotator cuff repair for the arthroscopic acromioplasty for the arthroscopic distal clavicle excision for the arthroscopic extensive debridement.

22 Orthopedic Case Study 2 A 21-year-old male who was struck by an automobile while riding his bicycle presents to the ED with a serious crush injury to the left lower extremity with massive swelling, ecchymosis, loss of sensation in the foot, and tightness of all four lower leg compartments and of the foot. He also complains of left elbow and shoulder pain. X-rays reveal a bicondylar tibial plateau fracture, left calcaneal fracture, left radial head fracture, and clavicle fracture. The orthopedist admits the patient. The patient undergoes immediate surgery to stabilize his fracture and treat his acute compartment syndromes of the lower leg and foot. The surgery involves a closed reduction of the tibial plateau fracture with application of an external fixator. The orthopedist plans open treatment of this fracture and the calcaneal fracture once the patient s fasciotomy wounds are closed.

23 Orthopedic Case Study 2 The code with the highest relative unit will be the code for the closed treatment of the tibial fracture LT (Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction; Left side). Next, report LT (Application of a uniplane (pins or wires in one plane), unilateral, external fixation system; Multiple procedures; Left side). After that, you should report the decompression leg fasciotomy code. Depending on the compartments released, you would report for anterior and lateral, for posterior only, or for anterior and/or lateral and posterior. You ll most likely report 27602, because the scenario describes all four compartments as tight. Depending on insurer, you might need modifier 51 on You can also apply modifier LT. For the fasciotomy, you should report (Fasciotomy, foot and/or toe).

24 Orthopedic Case Study 2 Question: Should you rule out adding modifier 59 to this claim? Answer: Yes. Neither code has separate procedure designation, and the combination isn t normally bundled. Adding modifier 59 to this claim is inappropriate because payers following CCI edits do not normally bundle these code combinations, nor do the codes have separate procedure designations.

25 Ob-gyn Case Study 1 One of your ob-gyn s regular patients is having twins, and your ob-gyn delivers them both vaginally. Two deliveries, however, do not mean you should submit two global ob codes. Reality: You should report the global code (59400) for the first baby and (Vaginal delivery only [with or without episiotomy and/or forceps]; Multiple procedures) for the second. Heads up: You should know your payer s preferences. Some insurance companies instead prefer that you bill the additional delivery with modifier 59 (Distinct procedural service) attached. Other payers will not pay anything additional for twin B when the delivery is vaginal.

26 Ob-gyn Case Study 2 You can report the tubal ligations following a vaginal delivery (59400, 59409, 59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use with modifier 59 (Distinct procedural service) appended. Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery, even though they occurred during the same session. Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.

27 Ob-gyn Case Study 2 Watch out: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the ob-gyn has already done the prep work for the patient prior to delivery and therefore, payers don t need to pay twice for the same work. In other words, they treat it just like any other multiple procedure. If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). You should receive full reimbursement for the procedure.

28 Separate Session Payers may be looking for evidence that the separate procedure was done during a separate encounter. Ex. A patient presented for a colectomy for colon cancer. The physician also discovered that the patient had a ventral incarcerated hernia that required a complex repair using mesh. Because of the separate work, we reported and then reported with modifier 59. The payer denied the claim. Were we wrong to append modifier 59? Mary Compton, PhD, CPC Answer: You might think modifier 59 would be appropriate for the hernia code and that you could bill it separately. But 59 tells the payer the hernia repair occurred during a separate session, which isn t true in this case. Modifier 22 (Increased procedural services) could apply here, provided you can support that extra work was done.

29 Look to Other Modifiers Rule #3: If a more specific modifier describes the situation, you should not use modifier 59. Modifier 59 should be the modifier of last resort and only used when there is no other modifier to compliantly bypass the bundling edit and the procedure was clearly distinct and different from that of the other procedure. ---Suzan Berman, CPC, CEMC, CEDC Senior manager of coding and compliance UPMC departments of Surgery and Anesthesiology.

30 Payment Reduction Quandary Scenario: The physician removes one lesion and biopsies another. Medicare pays the removal at 100 percent and the biopsy at 50 percent. The carrier applies this payment reduction even though you use modifier 59 on the bundled procedure -- the biopsy. Your dilemma: Should you find an alternative way to code encounters like this so that you can avoid the fee reduction?

31 Payment Reduction Solution The answer: Normally, a lesion removal includes a biopsy. To indicate that the biopsy occurred at a separate site from the lesion removal -- and thus deserves separate payment -- you must append modifier 59 to the otherwise bundled biopsy code. Don t miss: Although same-session, separate-site lesion removals and biopsies deserve separate payment, modifier 59 does not exempt the claim from multiple-procedure payment rule reductions, which you probably associate with modifier 51 (Multiple procedures).

32 Guideline Guidance CIGNA : Modifier 59 Policy Supporting Documentation (UPDATE) The list of code combinations requiring supporting documentation was reduced by approximately 25%, beginning May 17, Supporting documentation continues to be required on 79 code combinations, approximately 1% of claims submitted with a modifier 59. This update represents a significant reduction in the number of edits requiring documentation for dermatology services. The code pair list is available online with the Modifier 59 policy Source: CIGNA s Network News, July 2010

33 Resources CIGNA s Network News, July 2010, Modifier 59 policy ( > Resources > Clinical Reimbursement Policies and Payment Policies >Modifiers and Reimbursement Policies) CPT 2010 Professional Edition, AMA, Jan. 1, 2010 ICD-9-CM CD-ROM. Ninth Version. Centers for Disease Control & Prevention and the National Center for Health Statistics. Oct. 1, 2010 Medicare Physician Fee Schedule, CMS, Oct. 1, 2010 National Correct Coding Initiative, version 16.3, CMS, Oct. 1, 2010, United HealthCare, CCI Editing Policy, 2008R0105A, Dec. 9, 2009,

34 Save the Date! What Happened at AMA The scoop from the CPT and RBRVS 2011 Annual Symposium Register at: /conference without the expense! FREE Webinar Tuesday, Nov 23 12:00 pm EST Speaker: Jen Godreau, BA, CPC, CPEDC Observation coding changes You can recoup multiple vaccine components

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36 Ensuring reimbursement. Insuring coders. Questions: Mary Compton, Editorial Director Neurosurgery Jen Godreau, Content Director, Supercoder.com Family Practice, Pediatrics, Otolaryngology Suzanne Leder, Executive Editor Ob-Gyn, Orthopedics