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Published 12/1/2015
Mary LeGrand, RN, MA, CCS-P, CPC

That Was Then, This is Now

Frequently asked coding questions: Modifier 59 denials

Over time, coding recommendations or payer rules, including Medicare payer rules, change or are clarified. This article addresses a coding issue originally covered in the February 2014 issue of AAOS Now.

Modifier 59 denials'
The local Medicare carrier has recently denied multiple claims with the same Current Procedural Terminology (CPT) code reported more than once, using modifier 59 to indicate that the second procedure was performed at a different location. For example, the surgeon performed an open reduction/internal fixation of multiple metacarpal fractures. We reported 26615 once, and 26615-59 for each of the other fractures. Medicare paid the first code (26615) and denied the others as duplicates. How should this situation be reported?

A. Many local Medicare payers specify that modifier 59 should not be appended to a CPT code that is reported more than once. Instead, they require the use of modifier 76—repeat procedure or service by same physician or other qualified healthcare professional. A corrected claim can be submitted, appending modifier 76 to CPT code 26615 for each of the other procedures to indicate that the same procedure was repeated at multiple different locations.

Alternatively the local payer may want 26615 reported in units. Consider appealing with the XU modifier (unusual non-overlapping services) if a claim reporting units or using modifier 76 is denied.

Many Medicare contractors introduced the use of modifier 76 when a duplicate CPT code was reported and bilateral procedure rules were not met. However, even today, there is variability in using modifier 76 or reporting units when a duplicate code is reported and the bilateral procedure modifier does not accurately reflect the scenario.

Some payers may accept the RT/LT modifiers to indicate right and left side, others may require the use of anatomic modifiers (such as F1-F9 or T1-T9 to indicate fingers and toes), and still others may accept units. Some orthopaedic practices have found it necessary to report both modifiers (76 and 59) on the duplicate code or to use both modifier 59 and an anatomic modifier (T or F) on a duplicate code.

Rules related to fractures have changed. The type of fracture management will drive Medicare coding and payment rules related to the situation described. If a patient has multiple nondisplaced metacarpal fractures treated nonsurgically with a single cast, Medicare requires the use of CPT code 26605—Closed treatment of metacarpal fracture, single; with manipulation, each bone—to be reported and paid one time.

Thus, a surgeon would report 26605 for a Medicare patient with two nondisplaced metacarpal fractures treated without manipulation and a single cast for immobilization. But under CPT rules, for a private payer patient with the same condition and treatment (two nondisplaced metacarpal fractures treated without manipulation and a single cast for immobilization), the surgeon would report 26605 and 26605-59.

Remember, Medicare rules for Part B services apply only to Medicare patients; the Centers for Medicare and Medicaid Services (CMS) does not have jurisdiction over private payer reimbursement policies. The fact that CMS writes coding and payment rules for Medicare Part B is found in the National Correct Coding Initiative (NCCI) Guidelines updated at the beginning of each calendar year.

CMS has also addressed the difference between coding for Medicare patients and coding for commercial payers in an ICD-10 update released in July. In response to the question, "Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?" CMS responded as follows:

"The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities."

Although the topic is different, the concept is important. Physician practices need to follow CPT rules and the rules of the individual payers when submitting services to non-Medicare Part B payers. Medicare Part B NCCI are not written for private payers.

Continue to append modifier 59 for private payers according to the CPT definition for this modifier (separate site).

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.