Unbundling: When to Use Modifier -59 & Understanding CCI
by Erica Schwalm, CPC
CPT codes describe services provided to patients. Often, the service requires performance of multiple necessary “elements” to complete the total procedure. For example, when performing an open appendectomy, the physician would have to perform a laparotomy (incision into the abdominal cavity). Because the laparotomy (49000) is a necessary part of the appendectomy (44950), it should not be reported. The payment for 44950 includes the removal of the appendix, plus all services normally associated with the procedure (prepping the patient, opening the patient, closing the patient, etc.) If you were to submit both the 44950 and the 49000 to the insurance company, this would be considered unbundling. “Unbundling” is the practice of assigning multiple CPT codes to a service that could accurately be described by one code.
However, there are certain situations in which codes that would normally be considered bundled may be billed together. These situations may be reported using the appropriate anatomical modifier or modifier -59.
Per CPT: Modifier -59 (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 there is not a more descriptive modifier available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
If you turn to your CPT manual and read the guidelines for excision of benign lesions (code series 11400 – 11471) you will notice that these codes include simple closure. This means if the physician removes a lesion and then places stitches to repair the defect, you should report only the code for the lesion removal. But, let’s say you have a patient, who comes in for stitches for a cut on the leg, also happens to have a skin lesion on his neck that’s been bothering him. The physician repairs the leg wound with simple closure and also removes the skin lesion. If you submit the two codes together, they will deny because they are bundled. But, because they were done at two different anatomic sites, you should report the component code (in this case, the simple repair) with a modifier -59.
Also throughout the CPT manual, there are instructions indicating situations when modifier -59 should be used. For example, under codes 76818 and 76819 (fetal biophysical profile with or without non-stress testing), it tells you that assessments for any additional fetuses should be reported separately with modifier -59.
Another thing to watch for in the CPT manual are codes marked as “separate procedure”. The services described by these codes are often considered components of other services performed at the same time and should not be reported separately. However, if they are performed alone, they may be reported. These codes may also be reported when done on the same day as another service if they are unrelated or distinct. For example, Dr. Gyn dilates the cervical canal (57800) (separate procedure) and inserts an IUD (58300). Because the cervix is normally dilated when an IUD is inserted, it is considered an integral component and not reported separately. You would report only the 58300. But, if the dilation was the only procedure performed, then it would be reported.
According to CMS’s National Correct Coding Policy Manual for Part B Medicare Carriers (http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/manual.zip), codes designated as “separate procedure” “should not be reported when performed along with another procedure in an anatomically related region through the same skin incision or orifice”. Therefore, codes designated as “separate procedure” should only be reported if done at an anatomically unrelated site.
In addition to the CPT manual you must also check CMS’s National Correct Coding Initiative edits.
CMS’s National Correct Coding Initiative (NCCI – aka CCI), which can be downloaded for free at http://www.cms.hhs.gov/NationalCorrectCodInitEd/, was created to promote national correct coding standards and prevent improper payment of Medicare Part B claims. The CCI edits are built into Medicare’s claims processing system. Submitting two codes together that are considered to be bundled per CCI will result in a denial. To prevent such denials, whenever you have multiple services or procedures on the same day, you should check CCI before submitting the claim to ensure you are not unbundling.
CCI includes two different sets of edits:
1. The Column 1/Column 2 edits identify code pairs that should not be billed together because one service inherently includes the other.
2. The Mutually Exclusive edits identify code pairs that, for clinical reasons, are unlikely to be performed on the same patient on the same day.
When using CCI, you need to check both the Column 1/Column2 and the Mutually Exclusive folders.
The edit files, which are posted as Excel spreadsheets, are indexed by procedural code ranges for easy navigation. (If you were looking for CPT code 20610, then you would go to the file marked "20000-29999" in both the Column1/Column 2 folder and the Mutually Exclusive folder.) You can use the find feature in Excel to quickly locate the code you are inquiring about.
Each file is set up with two columns (A & B) that identify pairs of services that normally should not be billed by the same physician for the same patient on the same day.
The code indicated in the RIGHT column (column B) is bundled into the code indicated in the left column (column A). Under normal circumstances, the code in the column B should not be billed with the code in the column A, unless there is an indicator of “9” in column F, which means the code pair edit was a mistake and can be disregarded.
· If there is an indicator of “0” in column F, the codes can never be billed together.
· If there is an indicator of “1”, the codes may be billed together if appropriate.
The existence of a CCI edit indicates that the two codes cannot be reported together unless there is an indicator of “1” AND the two corresponding procedures are performed at separate patient encounters, separate anatomic locations, or on separate lesions. (Per CMS)
Just because there is an indicator of “1” does NOT mean you can automatically add the -59. This is a fraudulent billing practice. You must ensure that the services are truly distinct before appending a modifier.
In fact, according to a report by the OIG (http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf), “Forty percent of code pairs billed with modifier 59 in FY 2003 did not meet program requirements, resulting in $59 million in improper payments”.
Check the documentation in the patient’s medical record. If documentation does not support the distinct nature of the services, they should not be reported.
A. 20550 is bundled into 20610 with an indicator of “1”, so, if a provider injected both a ligament and a joint of the same shoulder, you would not be able to bill both codes per CCI. However, if the provider injected a ligament of the LEFT shoulder and a joint of the RIGHT shoulder, this would be considered a separate anatomical location and would be appropriately billed together. Use of anatomical modifiers –LT and -RT would allow the claim to get paid by bypassing the edits. (Consult your CPT manual for a complete list of anatomical modifiers.)
B. 94664 is bundled into 94640 with an indicator of “1”. If a patient had an appointment in the morning that included a nebulizer treatment and inhaler teaching, you would not be able to bill the 94664. On the other hand, let’s say a patient had a morning appointment and also had inhaler teaching. If, later in the same day, the patient had an asthma attack and returned to the same physician for a nebulizer treatment, you would be able to bill for both services because they were done at separate patient encounters. Under these circumstances, anatomical modifiers do not apply so use of modifier –59 is appropriate. Submit the code in column B, in this case the 94664, with a –59 modifier.
For additional information and examples, read Medicare’s article on proper usage of modifier -59: http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf