The most significant error in his methods is the use of modifier -59 to allow performing fundus photography (CPT 92250) and SCODI (92135) on the same day or session. These two codes are prohibited from being performed on the same day because they are considered to be a “Mutually Exclusive” code pair by the National Correct Coding Initiative (NCCI). Contrary to Mr. Rebello’s assertion that these rules are regional, the NCCI are federal rules and not local as implied within the article. Additionally, his claim that you must simply indicate multiple dissimilar diagnoses is not enough to use this modifier. Using modifier -59 to override this code-pair rule denial is not only incorrect, but flies in the face of specific CPT guidelines and rulings from the Office of Inspector General (OIG).
The CPT defines modifier -59 in terms of a distinct procedural service: “Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”
The NCCI rules go further to say “Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.” (The emphasis is mine.)
NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters. Carrier processing systems utilize NCCI-associated modifiers to allow payment of both codes of an edit. Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
One of the misuses of modifier -59 is related to the portion of the definition of modifier -59 allowing its use to describe “different procedure or surgery.” The code descriptors of the two codes of a code-pair edit usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use modifier -59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier -59 may be appended to indicate that they are different procedures/surgeries on that date of service.
The CPT and NCCI rules, and the subsequent position of the OIG, clearly demonstrate that Mr. Rebello’s application of modifier -59 is incorrect. Here’s exactly what the NCCI guidelines say: “Use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier -59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters. [Again, the emphasis is mine.] From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site.”
Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site.
As a lecturer on coding for nearly 25 years, safety for my fellow practitioners is my primary objective. I am concerned about putting our fellow practitioners at risk if they follow the coding examples outlined in this article. Inappropriate use of a modifier to bypass the rules places an individual on a slippery slope. Safety and compliance with the existing rules and regulations, not monetary gain, should be the primary goal when providing advice/examples of coding medical procedures, and not simply the criterion of getting reimbursed by the third-party carrier. While using modifiers like these will often get you paid by the carrier, it is reckless without the full understanding of the complete definition, background, appropriate application of use, and ramifications of inappropriate use.
As one who frequently defends practitioners in audits, I can say that preventing mistakes by a thorough understanding of all aspects of coding your procedures prior to submitting the claim is far better than just coding to get paid.
In this case, asking for forgiveness rather than permission just doesn’t apply.
—John Rumpakis, O.D., M.B.A.
Clinical Coding Editor, Review of Optometry
Lake Oswego, Ore.
