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One of the most common things I see during facility audits is the misuse and overuse of modifier -59, distinct procedural service, which inadvertently snowballs into the unbundling and upcoding of surgical procedures. Not only does the application of modifier -59 to each CPT code listed in an operative session warrant closer scrutiny from my team, but it also waves an ominous red flag for Medicare and the Office of Inspector General (OIG).
In one OIG study of 341 claims, facilities incorrectly reported modifier -59 in 40 percent of the cases, resulting in CMS's overpaying claims by more than $50 million. With Medicare already making millions of dollars in overpayments, you can count on fiscal intermediaries and commercial carriers reviewing more of the claims you submit with modifier -59. Here are the four most common reporting errors we see when we audit surgical claims.
1. Modifier -59 used to mimic modifier -51. Frequently, a facility will inappropriately append the -59 modifier just as a physician's office would append the -51 modifier to each of its codes to indicate multiple procedures were performed at the same session. Kudos to you if you're aware that modifier -51 is a physician modifier and that facilities shouldn't report it under normal circumstances. Facilities should keep in mind modifier -59 by definition indicates that the normally "bundled code" represents a service done at a different anatomic site or at a different session on the same date. Further, it's not necessary to automatically apply modifier -59 to a CPT code if it doesn't normally "bundle" into another CPT code.
2. Modifier -59 used to bypass Medicare edits. Don't misinterpret the Medicare edits. Simply because a CPT code "allows" a modifier doesn't mean the procedure itself is always an "allowed" procedure. To put it another way, you can use a modifier for a separate and distinct procedure when the operative documentation clearly supports the separate and distinct procedure. Don't append the modifier -59 simply to get the claim past the edits and be reimbursed. Remember, just because a claim was paid doesn't mean it was paid correctly. Once a carrier determines it has overpaid your claim(s), it will expect an immediate refund and may take back payments without notice. The practice of unbundling integral components of an operative procedure is certain to open up a can of regulatory worms.
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Coding Complex Cataract Cases |
It's not uncommon for surgical centers to inappropriately assign code 66982 when the OR report doesn't support the code. Three CPT codes are available for one-stage cataract extraction with intraocular lens insertion, but you can only assign 66982 for "complex" cases.
CPT 66982 classifies the amount of work and extraordinary surgical activities that are required for patients in the pediatric population group (younger than 8), or who present with a weakened or absent lens support structures (small pupil, subluxated lens and pseudoexfoliation, for example) due to a diseased state or infection (such as pseudoexfoliation syndrome, trauma, Marfan syndrome, glaucoma and uveitis), according to the CPT 2001 Coding Symposium.
Cataract extraction in glaucoma patients can require complex techniques or maneuvers to extract the cataract and insert the IOL. For example, chronic administration of pupillary constriction medication (miotics) for glaucoma often reduces the pupillary response to mydriatics (drugs that cause pupillary dilation) administered before the extraction procedure. To overcome this situation and allow visualization of an access to the lens, the surgeon may need to use an iris expansion device, such as iris retractors (flexible retractors hooked onto the pupillary edge of the iris), to enlarge and maintain the pupillary opening during lens extraction and IOL insertion. In other situations, the physician may be able to accomplish dilation by performing multiple sphincterotomies in the iris (tiny, radial incisions in the sphincter muscle of the iris). Note that dilation of the iris by manually stretching it with a hook inserted through the same incision doesn't justify the use of code 66982.
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3. Appending modifier -59 to the wrong CPT code. Often, a coder may apply the modifier -59 to the comprehensive CPT code rather than the component code. If clinical documentation supports a separate, distinct procedure, append modifier -59 to the integral component code. For example, you may report both a removal of a polyp in the transverse colon by snare technique and a cold forceps biopsy of a polyp in the ascending colon because work was performed on two different polyps by different techniques. Normally, CPT code 45380 is an integral component of the comprehensive CPT code 45385 and isn't separately reported. However, since a separate and distinct procedure was performed, we would append modifier -59 to 45380 (45385; 45380-59).
4. Appending modifier -59 to codes with "separate procedure" in its verbiage. A common misconception is that you should separately report a CPT code with the parenthetical statement "separate procedure" in its verbiage with modifier -59 regardless of the circumstances. Another coding faux pas. A CPT code that includes the parenthetical statement "separate procedure" indicates that the procedure can be performed separately but should not be reported when performed at the same session as a related primary procedure. Once again, clinical documentation must detail a separate and distinct procedure to append the -59 modifier to a CPT code with "separate procedure" in its description when performed with a primary procedure. Under-standably, modifier -59 would not be reported if the CPT code with the "separate procedure" inclusion is the only procedure performed.
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