The most commonly used procedural modifiers

Cracking the Code

Dirk Elston

Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

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Payment for surgical procedures already includes payment for some pre- and post-operative services related to the surgery, whether furnished by the physician who performed the surgery or by members of the same practice group if they practice the same specialty. This article discusses the most common modifiers used to report services that should not be bundled into the global surgery package.

59: Distinct procedural service

Modifier 59 is an important Medicare National Correct Coding Initiative (NCCI)-associated modifier, most often used incorrectly. Its primary purpose is to indicate that a procedure or service was distinct or separate from other services performed on the same day. The most common scenario would be a separate procedure for another lesion at a second site. It can also be used to indicate distinct services rendered during a separate session or patient encounter on the same date of service. In either case, modifier 59 is attached to the secondary procedure (see the previous article in this series on CCI edits, May 2011). Modifier 59 is used in conjunction with procedure codes and should never be appended to an evaluation and management (E/M) office service code. It should be used when no other valid modifier exists (such as modifiers for the left and right — LT and RT).

Note: Modifier 59 is an audit trigger and as such, should be utilized when there is absolutely no other modifier that can/will appropriately describe the relationships of the two or more procedure codes reported.

79: Unrelated procedure or service by the same physician during the post-operative period

Modifier 79 is used to indicate the performance of a separate and unrelated procedure during a post-operative global period. It may be best to think of it as similar to 59 but occurring during the global period rather than on the same date of service as the original procedure.

50: Bilateral procedure

Bilateral procedures are sometimes performed on both sides of the body during the same encounter. The most common scenario for a dermatologist would be application of bilateral Unna boots which is reported on one claim line as 29580 -50, remembering to increase the allowable amount by at least 150 percent.

58: Staged or related procedure or service by the same physician during the postoperative period

Modifier 58 is used to indicate a staged procedure planned in advance or a re-excision for a positive margin during a global period. As with the previous modifiers, it is appended to a surgical procedure code.

25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

Modifier 25 is different from the preceding codes in that it gets attached to the E/M code to indicate that the patient required a significant, separately identifiable E/M service beyond the customary pre- and post-operative care associated with the procedure. The separate cognitive service may relate to the same diagnosis as the procedure, but must be medically necessary and clearly separate from any cognitive service related to performance of the procedure itself. The acid test is to block out all documentation of pre- and post-op counseling to determine if what remains justifies a separate E/M code. More commonly, the modifier 25 will relate to a separate diagnosis. As always, the cognitive services must be appropriate and medically necessary.

24: Unrelated evaluation and management service by the same physician during a post-operative period

Modifier 24 is similar to modifier 25, but is used during a post-operative global period. Like modifier 25, it indicates an unrelated E/M service. When a surgical procedure is performed during the global period, one needs to append both modifier 24 and 25 (in that sequence) on the E/M service to show that a separately identifiable E/M service was performed during the global period of another unrelated procedure.[pagebreak]

57: Decision to perform surgery

Medicare recognizes modifier 57 to indicate E/M services related to the decision to perform a medically necessary major surgical procedure or those procedures associated with a 90-day global period. Medicare carriers have issued guidance that this modifier must not be used in association with minor surgical procedures such as those with a zero- or 10-day global period as they consider the decision to perform those procedures to be part of the usual pre-operative services bundled with the payment for the procedure. Modifier 57 should typically not be reported for prescheduled surgeries, as the decision to perform those was already reached in advance.

Example 1:

You perform an excision of a basal cell carcinoma on Monday and see the patient the next week to treat an unrelated episode of erythema multiforme. You append modifier 25 to the E/M code.

Incorrect: This represents a separate and distinct service, but the care occurred during a global period. Modifier 24 would have been appropriate.

Example 2:

You excise a squamous cell carcinoma on the leg and the margin is reported as positive. A week later, you remove additional tissue and append modifier 58.

Correct: Modifier 58 is used to indicate a staged procedure planned in advance, but is also appropriate to use for a re-excision for a positive margin during a global period.

Example 3:

You excise a presumed melanoma and also biopsy a presumed basal cell on the same day. Use modifier 59 to indicate that the procedures were performed on two distinct lesions.

Example 4:

You sample a portion of a suspected basal cell carcinoma by means of shave technique, curette the base of the lesion, and send the specimen to the lab.

This was a single lesion, so it would be inappropriate to report shave, biopsy, and destruction of the same lesion.

In order to receive the full reimbursement for the medically necessary services you provided, wait until the pathology report is received. If the report confirms that the lesion was a basal cell carcinoma, report only destruction of the malignant lesion. The correct diameter to report is the final diameter of the curettage defect.

If, on the other hand, the report confirms that this was merely a pearly benign melanocytic nevus, report only the biopsy as this was the medically necessary service. As your intent was to sample a portion of the lesion, you should use the skin biopsy code rather than a shave code. Shave codes are used when your intent is removal of the lesion while remaining in the dermis.

Example 5:

You see an established Medicare patient for a new lesion on the nasal tip. You perform an appropriate history and physical examination and make the decision to perform Mohs micrographic surgery with closure by means of an adjacent tissue transfer. Mohs has a zero-day global period, but the flap closure has a 90-day global period. The E/M services provided, including the decision to perform surgery, would be reported with modifier 57.

Example 6:

You excised two 8-mm squamous carcinomas, one from the left forearm and one from the right forearm. You report both procedures with a 59 modifier.

Partly correct. While many payers are likely to process the claim with the 59 modifier, the more specific RT and LT modifiers would be more accurate. Readers are advised to check with their individual payers for guidance.