Avoid claim denials by using modifier 59 correctly

Casselberry, Fla. - Incorrect use of modifier 59 in dermatology is the single most common reason for claim denials by Medicare and commercial insurance carriers, according to Inga C. Ellzey, M.P.A., R.H.I.A., C.D.C., president and chief executive officer of Inga Ellzey Practice Group, Casselberry, Fla.

Dermatology is a very complicated specialty when it comes to billing, according to Ms. Ellzey.

“Dermatologists provide a lot of services on a single date of service. It is not uncommon for four or five CPT (current procedural terminology) codes to be on a claim form, which is not the case with a lot of other specialties,” she says.

Modifier 59 is a same-day modifier; in other words, it is the code used on services that are provided on the same day of service. It is Medicare’s way of identifying services that should not be billed together because they encompass each other.

“I always use the example that it is like going to Wendy’s and ordering a single. You would be mad if Wendy’s said, ‘OK, that will be $1.79 for the single and $.35 for the bun,’” Ms. Ellzey says. “So, what [Medicare] is saying is a lot of doctors have started to piecemeal services that are already represented by a single code, and billing the second code is unbundling - it is billing for what you have already done.”

Dermatologists can bill for same-day services, however, if they are from different sites or are different lesions. That is where the 59 modifier comes in.

Be current; don’t guess

Ms. Ellzey says there are two things that every dermatology practice needs to know in order to correctly charge for services using the modifier.

First, Medicare releases a new version of its Correct Coding Initiative every 90 days. Always work from the newest version, because things do change. Without the newest versions, dermatology billing staff is left to guess, which is likely to result in denial, according to Ms. Ellzey.

Dermatology staff can get the latest version for free the National Technical Information Service (NTIS) Web site at http://www.ntis.gov/, from the Federal Register at http://www.gpoaccess.gov/fr/, or dermatologists can purchase the DermCoder, a user-friendly resource developed the Inga Ellzey Practice Group at http://www.iepg.com/products/cci.htm.

Ms. Ellzey also recommends that practices keep on hand at least one year’s worth of the older Correct Coding Initiative versions, in order to use the appropriate version for appeals and redeterminations on unpaid claims.

Commercial carriers have, for the most part, adopted Medicare’s rules for modifier 59.

“Some follow exactly as Medicare has developed it and some of the commercial carriers … have tweaked it,” she says.

Ms. Ellzey says it is generally a good practice to use Medicare’s approach to bundling with all carriers; then, if the dermatologist gets a rejection from a non-Medicare carrier, that physician would work with the carrier to find out how it wants the bundling to be presented on the claim form.

Dispel modifier myths

A misleading and common myth about modifier 59 is that one should use the modifier on the CPT code that has the higher charge, or higher relative value.

“The truth is that modifier 59 has nothing to do with payment; it does not have anything to do with the charge. It only has to do with overriding the computer edits that will allow you to get paid for both those services on the same day, if they are bundled,” she says.

Still, others believe the modifier should go on the most comprehensive service.

“Payment, charges, relative value units have nothing to do with the use of 59 modifier. Sometimes it goes on the most expensive CPT code, sometimes on the cheaper one. It just depends on the bundle,” Ms. Ellzey says.

Expect more denials

According to Ms. Ellzey, more carriers are denying use of modifier 59 when it is not required. She says that systems for payment are set up for twins - two codes bundled together. Both appear on the same claim. If they are from the same lesions, the one in the component column is going to be eliminated. If they are unrelated, then the dermatologist can bill both, but the one in the component column is going to get the 59 modifier. The dermatologist who adds the 59 modifier to a service that is not bundled will most likely trigger a denial because the system looks for a bundled pair.

“You are saying it is bundled with something, but, according to the tables, there is no bundling combination. I see that all the time. If you do an excision and a repair, they are not bundled, and you do not need a modifier. But I would say 50 percent of staff members will put a modifier on one of the two,” Ms. Ellzey says. “[Modifier 59] is such an important modifier, and the staff has to master it and stop guessing.”