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Proper use of Modifier 59: Understanding the new sub-codes


Answers to reader questions about the proper usage of Modifier 59, getting paid for vaccine administration, and more

Q: Can you please explain the new sub-codes for modifier 59 and how to use them?

A: According to the 2013 Comprehensive Error Rate Testing (CERT) Report data, a projected $2.4 billion in Medicare Physician Fee Schedule (MPFS) payments were made on lines with Modifier 59, with a $320 million projected error rate.

The Centers for Medicare and Medicaid Services (CMS) considers Modifier 59 to be the most widely- used Healthcare Common Procedure Coding System (HCPCS) modifier because it is defined for use in a wide variety of circumstances. Since CERT findings show a widespread misuse of Modifier 59, CMS reiterated last August that the -59 modifier is used to define a “distinct procedural service.” Currently, providers can use the modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

In addition, CMS reports that some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)” and thus is associated with considerable abuse. Modifier 59 has high levels of manual audit activity, which leads to reviews, appeals and even civil fraud and abuse cases.

Unfortunately, not much additional information has been published regarding the use of these modifiers. Here is the only information that Medicare has offered for these new modifiers:

These modifiers should never be appended to Evaluation and Management (E/M) codes and should only be used when another modifier doesn’t exist to describe the situation.

However, not knowing what insurance you are billing to, my best advice is to contact the carrier directly.

As of this time, Anthem has stated that it considers these modifiers to be informational only and thus the use of Modifier 59 will still be necessary to override any claim edits, when appropriate.

It is not clear if other payers will follow CMS guidance and require the new modifiers or if they will still require Modifier 59 and consider the new modifiers informational only. Check with your payers for further direction on the use of Modifier 59 and the new X-modifiers developed by CMS.


NEXT: Does Medicare now cover Prevnar 13 and the pneumovax vaccine?


Q: I understand that Medicare has agreed to cover the new Prevnar 13 and a year later the pneumovax vaccine for patients over 65 years old. Is this correct?

A: Yes, you are correct that CMS has updated their coverage requirements to align with the updated Advisory Committee on Immunization Practices (ACIP) recommendations. With an implementation date of February 2, 2015, MLN Matters® Number MM9051 reported that Medicare coverage requirements will align with the ACIP recommendations.

Therefore, Medicare will cover:

  • an initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and

  • a different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months following the month in which the last pneumococcal vaccine was administered).

Since the updated ACIP recommendations are specific to vaccine type and sequence of vaccination, prior pneumococcal vaccination history should be taken into consideration.

For example, if a beneficiary who is 65 years or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series of the two recommended pneumococcal vaccinations. Receiving multiple vaccinations of the same vaccine type is not generally recommended. Ideally, providers should have ready access to vaccination history, such as with electronic health records, to ensure reasonable and necessary pneumococcal vaccinations.

Medicare does not require that a doctor of medicine or osteopathy order the vaccine; therefore, the beneficiary may receive the vaccine upon request without a physician’s order and without physician supervision.

Note that MACs will not search for and adjust any claims for pneumococcal vaccines and their administration, with dates of service on and after September 19, 2014. However, they may adjust any claims that you bring to their attention. For more information, refer to MM9501.

I recommend that you review your vaccine denials and bring any pneumococcal vaccines denied to the MACs attention in order to receive reimbursement, otherwise you will not be reimbursed for vaccines you have already provided.

Q: I’ve been researching coding guidelines and am finding conflicting information. How do I get some clarity on this?

A: It has happened to all of us. We research a coding subject and find differing answers. Insurance carriers will have different guidelines, so make sure which insurance is applicable for the scenario you’re researching. Also, keep in mind that there are times when the Current Procedural Terminology (CPT) instructions differ from CMS instructions.

One example is the use of Modifier 51. The CPT definition of this modifier is, “When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).” CPT also instructs to append this modifier to the second procedure when two procedures are performed on the same date of service.

CMS instructs that Modifier 51 should not be billed by the provider because Medicare uses this as a payment modifier and applies it when necessary.

Another example is the new patient decision tree. While the decision tree includes physician subspecialty as a designation, Medicare does not use the physician subspecialty as a determining factor.

The bottom line: Be sure to check the CPT, CMS and insurance carrier’s billing instructions before submitting a claim.

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.

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