Master CCI Edits For Shoulder Surgical Procedures

Use modifier 59 inappropriately, and it can cause you a “bundle” of problems

To get paid for all you do, you must correctly code each and every procedure performed—which sometimes means unbundling codes using modifier 59 (Distinct procedural service). However, to decide if and when modifier 59 is appropriate, you must do some heavy lifting.

Appending modifier 59 to a CPT code is not an action you should take lightly, suggests coding expert Margie Scalley Vaught. In her live audio conference, “Master 2019 Shoulder Surgical Procedures: Pick the Right Codes Every Time,” Vaught explains that when you use modifier 59, you’re reporting and requesting to be paid for two or more procedures that would normally be bundled—you’re breaking a CCI edit. For that reason, modifier 59 is continually under regulatory scrutiny.

Beware: Misusing modifier 59 may be considered abuse or even fraud. Plus, you could be liable for any overpayments you’ve received. To stay off auditors’ radar and safeguard your revenue, knowing exactly when and how to use modifier 59 is essential.

Take These 5 Steps Before Choosing Modifier 59

Coding for shoulder surgical procedures is already tricky, and the new CCI guidelines only add to the complexity. Follow these five steps before choosing modifier 59:

  1. When documentation indicates that a surgeon performed multiple procedures on the same patient on the same day, the very first thing you should do is check CCI edits for any bundled codes, as outlined by the Centers for Medicaid and Medicare Services (CMS) guidelines
  2. Once you’ve found your code pair in the CCI edits, check for indicators. If the indicator is “9,” the codes aren’t bundled, and you can bill them separately. Codes with an indicator of “0” may never be unbundle Codes with an indicator of “1” may be unbundled—but that doesn’t mean they should be.
  3. For codes with an indicator of “1,” determine if modifier 59 applies. The “distinct” in Distinct procedural service means the services you want to unbundle were performed at a different anatomical site or organ system, surgical session, incision, lesion, or injury.
  4. Next, consult any payer-specific guidelines. Modifier 59 should only be used if there is no other appropriate modifier—it’s the last resort. For example, LT, RT, and Medicare’s X modifiers (XS, XE, XP, and XU) offer more specificity than modifier 59. If a more appropriate modifier applies, use it instead.
  5. Finally, if you’ve determined that modifier 59 is appropriate, append it to the secondary procedural code (the code in column 2 of the CCI edits).

Example: Medical record documentation indicates the surgeon performed an arthroscopic capsulorrhaphy 29806 on the patients right shoulder and a partial synovectomy 29820 (synovectomy, partial) on the patients left shoulder, on the same day and during the same surgical session.

According to the CCI edits, 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) and 29820 (synovectomy, partial) are bundled with an indicator of “1.” Since the procedures were performed on a different anatomical site, they qualify as distinct procedural services.

The patient has private payer insurance, so the X modifiers don’t apply. However, modifiers RT and LT are a better choice, according to this CMS documentation on the proper use of modifier 59. Therefore, you would not append modifier 59 to 29820.

Tread Carefully When The Surgeon Changes Gears

When the documentation indicates that a surgeon began the surgery with one approach and ended with another (on the same anatomical site), it’s not uncommon for coders to erroneously report both procedures and append modifier 59 to one of them. However, you may only report the code for the final approach that the surgeon completes, according to the NCCI Policy Manual.

Example 1: The surgeon started to perform a rotator cuff repair arthroscopically (23410) but switched to an open procedure (29827). You’d only report 29827.

When using modifier 59, ensure that the documentation supports it, emphasizes Margie Scalley Vaught. The operative report must clearly indicate that the secondary procedure fits into one of the scenarios where modifier 59 is warranted. In addition to bundling, Vaught will go over all of the shoulder coding and documentation changes for 2019 in her live audio conference, “Master 2019 Shoulder Surgical Procedures: Pick the Right Codes Every Time,” including how to code new techniques and procedures.

To join the conference or see a replay, order a DVD or transcript, or read more

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