Modifier 59 - Are You Using It Correctly?
Did you know one of the main reasons for claim denials and revenue loss is the incorrect usage of modifiers?
Undoubtedly, medical bills are being
claimed in a combination of codes for the services performed in the medical
practice. But that is not all required. The accurate coding of such corresponding
treatment modifiers is mandatory to ensure the reimbursement of these claims,
including Modifier 59 (Distinct Procedural Service). In fact, the claim form
also needs to have diagnosis codes along with proper ICD 10 codes.
If you are wondering why, you should be
concerned about whether you are using Modifier 59 correctly, the reason is that
it is one of the most misused modifiers. Unfortunately, you would not be alone
and lose your revenue for the failure to use Modifier 59 correctly.
What
Is Modifier 59 Used For?
Typically, Modifier 59 indicates that
more than one procedure is performed on the patient in a single visit. But such
procedures should be on the different part of the bodies.
However, at times, it is used to bypass
the edit system of the insurance carrier and avoid being bundled with another
service on the same claim.
Going by the guidelines, it should never
prevent a service from getting bundled with the other.
Modifier 59 is developed to indicate a
physician's service on the patient during the same visit whereby the procedures
are independent of each other. Such modifier helps in reporting the services
usually performed together, but it can be done under certain circumstances, as
deemed fit by the physician.
Are
You Adding Modifier 59 Correctly?
As a claimant, you must be aware that
Modifier 59 is used correctly with other modifiers. For instance, you cannot
include Modifier 59 with Modifier 76. Thereby, your claim will get rejected
altogether.
The reason is that Modifier 76 is used
for stating the same procedure being performed on the patient multiple times on
the same day by the same physician after the initial consultation.
Whereas Modifier 59 indicates different
sessions, surgery/procedure, different site/organ, incision or excision, injury
treated that were not part of the previously reported procedure. The same
physician does these other procedures on the same day after performing the
initial procedure scheduled for.
The physician also performs the
unscheduled procedure during the treatment because he deems fit for the
betterment of the patient.
Are
You Using Modifier 59 Indiscriminately?
The National Correct Coding Initiative
(NCCI) promotes the
usage of correct coding and prevents improper payment often leading to the conduct
of audits. However, to bypass the NCCI edits, the practices often misuse the
modifiers.
Whether it is done by purpose or
mistake, a practitioner has to be mindful of not using Modifier 59
indiscriminately.
Undoubtedly, the practices append modifier
59 to a diagnostic procedure performed following a therapeutic procedure.
However, when the diagnostic service is part of the therapeutic procedure, the
modifier is used arbitrarily.
Who
Can Use The Modifier?
In a practice, one needs to be aware
that only a coder or provider of the service who has access to the patient's
chart can add the modifier 59. It can never be used by the biller, even when
the biller knows that without the modifier will result in claim rejection or
bundling.
You have to go back to the service
provider when you believe Modifier 59 is omitted from the claim as a biller.
You should always have substantial evidence to get back the Modifier 59 claim.
What
Are The Guidelines For Using Modifier 59?
You can easily find the guidelines for
using Modifier 59 in detail at the Medical Learning Network.
But the basic principles of the Modifier
59 are:
•
For
appending Modifier 59, new diagnosis is to be made
•
A new
diagnosis does not qualify for Modifier 59 if new treatment does not follow
•
The
modifier should not be used to bypass the edit when the above criteria fail to
meet
•
In the NCCO
table, in Column 2 code, Modifier 59 should be appended
•
It is not a
management or evaluation modifier
•
Every
documentation needs to be done clearly by the physician for Modifier 59
•
Just
because the software asks you to add Modifier 59, don't add it. Instead, one
must read the documentation in detail to ensure whether it should be added or
not.
Use
the Modifier 59 Correctly – Get the Timely Claims!
The improper use of a modifier is not
limited only to Modifier 59. In fact, the practices often use other modifiers inappropriately
such as 24, 25, 50, 51, and 76. These modifier coding mistakes
can easily be avoided when it is being done by a professional medical billing company such
as 24/7 Medical Billing Services. This is one of the best alternatives, i.e., to connect with
experts who are well-trained in the medical coding and stays at the top of the changes
done into this coding system, so that your claims will never fail or come under
audit because of overbilling.
About 24/7 Medical Billing Services:
We are a medical billing company that
offers ‘24/7
Medical Billing Services’ and support physicians, hospitals, medical
institutions and group practices with our end to end medical billing solutions.
We help you earn more revenue with our quick and affordable services. Our
customized Revenue Cycle Management (RCM) solutions allow physicians to attract
additional revenue and reduce administrative burden or losses.
Contact:
24/7 Medical Billing Services
Tel: +1 888-502-0537
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