Auditing tips for modifier 59

Verifying that a claimed service is truly distinct

Auditing modifiers--the two-digit codes attached to procedure codes to alter their descriptions--plays a key part in verifying that claims for healthcare services were filed accurately and processed correctly. One modifier that's been misused is 59, which signals that a service is distinct from other procedures rendered to the same patient on the same date. Providers have used modifier 59 to bypass edits preventing separate payment for services that shouldn't be claimed together, the Office of Inspector General found. Overbilling has resulted.

The Centers for Medicare & Medicaid Services created "spinoff" modifiers associated with 59 to show why a service is distinct. These take effect next year. CMS has encouraged providers to view modifier 59 as the choice of last resort to be used only when a more descriptive modifier (such as a spinoff) isn't available, according to a RACmonitor article.

The article also offers tips to verify correct use of modifier 59.  

"It is within the [medical record] documentation that we find whether each modifier is supported or [whether] it should be removed as a billing component on the claim for the service," the article noted.  

For correct use of 59, CMS guidelines state that "documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual" RACmonitor added.  

Payers should look for documentation that specifically identifies "the absolution between the two procedures," the article advised. The record, for example, should identify different body parts associated with the claim or separate sites of service or injury.

"Not only does CMS indicate that a provider's documentation should always paint a portrait of the patient," the article noted, "but the provider's documentation should have very clear detail to accurately convey the complexity and the appropriate medical necessity to not only support the actual service, but also the use of modifiers such as the 59."       

For more:
- read the RACmonitor article

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