Medical Billing Forum

Billing => Billing => Topic started by: MedBiller on August 30, 2010, 08:15:12 PM

Title: Appropriate/proper 59 modifier usage
Post by: MedBiller on August 30, 2010, 08:15:12 PM
As usual, thanks for any assistance provided...

Need clarification regarding infamous "modifier 59"

I understand that it represents a procedure that is distinct or independent from other services performed on the same date. When appropriate; I have used it in the following scenario: E/M service with modifier 25 and 96372 with modifier 59. If applicable, How would I utilize it properly when billing the following?  Can I use it more than one? 

99214 w/ mod 25  (office visit level 4)
36415  (vein.)
85025  (CBC)
96365  (initial hour non-chemo infusion)
96366 X 2  (additional hours non chemo infusion)
96367  (Subsequent hours non chemo infusion)
96361  (additional hours hydration)
96372  (B12 injection)

I was taught to place the 59 modifier on the primary procedure code only (96365), but I believe that might be incorrect.  Thanks! 

Title: Re: Appropriate/proper 59 modifier usage
Post by: Michele on August 31, 2010, 08:32:24 AM
I am not a certified coder so I am not sure.  IMO, the 59 modifier is not needed since you are using the 25 on the E&M.  However, I am wondering if you are a coder.  If you are not, shouldn't the charges be coming over to you with the modifiers indicated by the provider?  Just wondered.

Title: Re: Appropriate/proper 59 modifier usage
Post by: medauthor on August 31, 2010, 09:54:58 AM
I am going with Michele here....but take a look at what CMS says (
Title: Re: Appropriate/proper 59 modifier usage
Post by: oneround on August 31, 2010, 10:43:36 AM
The ladies have given somne really good points here.  i would let your coder handle this and and I say this because mod. 59 is a highly misused modifier and has been abused big time by many.  This mod. is highley subceptible to audits and was a main focus point for the OIG at one time.  Mod. 59 does not have to be coded on the primary procedure but is placed on the code that is usually bundled into the primary procedure.  Again, this is a high profile modifier and as the ladies stated

THER/PROPH/DIAG INJ, SC/IM M 96372 is a component of Column 1 code 96365 but a modifier is allowed in order to differentiate between the services provided  (Again when in doubt-send it back to the coder to cehck it out)
Title: Re: Appropriate/proper 59 modifier usage
Post by: medauthor on August 31, 2010, 01:40:14 PM
96372  (B12 injection)

I just realized....where is your J3420? Is this on your claim, as well?
Title: Re: Appropriate/proper 59 modifier usage
Post by: MedBiller on August 31, 2010, 05:15:25 PM
Thank you for all your responses.  My apologies for posting this in the billing vs. coding section.

In doing my own research, it has become apparent that I am in a unique situation.  I'm employed as a medical biller for a specialist group who keeps their billing in house.  Having no formal training, I was taught on the job by my peers.  It has come to my attention, that there are certain aspects to my training that are lacking in regards to the proper way to bill, hence my request for assistance.   We also are responsible for the coding of our claims.  I hadn't realized how outlandish this all was until I started utilizing your forum.  So, please bare with me and my questions, for I am just trying to educate myself.

With that being said, there is no coder to consult. 

I did neglect to include the J3420, if we are providing it, then yes, I do bill for it, however there are times when the patient brings their own supply.

Title: Re: Appropriate/proper 59 modifier usage
Post by: PMRNC on September 01, 2010, 06:49:54 PM
If there is no coder the claims should get sent to the doctor to code. He is in there with the patient, he should either be coding himself or hire an on-staff coder.  Whether you are an employee or not will not negate the liability you will have for any problems down the road..I would definitely go to your office manager and explain that you are uncomfortable with the coding.
Title: Re: Appropriate/proper 59 modifier usage
Post by: BREWERBILLING on March 09, 2011, 10:49:07 AM
I am in the same situation with our office.  While the doctor is in with the patient and does "code" in Amazing Charts -- they do not do the 1500 from there -- I only get the patient notes so there is no where for them to put the modifier.  I know that 25 goes with all injections and that 51 is used on occasion, but it is really trial and error to learn it.  I have reviewed our previous billers superbills to gain insight into the uses.  Also, in our area there is little opportunity for training and the online stuff seems more shady than real. Any advice on training?
Title: Re: Appropriate/proper 59 modifier usage
Post by: pattil88 on March 10, 2011, 02:12:16 PM
Speaking from my coding side of the fence, you may want to check with the AAPC (American Academy of Professional Codes) to see if any local organizations are offering coding classes. Some groups may also offer training for a particular specialty but they can be costly.

In my career, I've learned there can be a big difference in "technically correct coding" and the payer world's interpretation of all of the codes and modifiers. The bilateral modifier -50 comes to mind. Some codes are already described in CPT as "bilateral"; however, some payers will say to still use a -50 on them, some will say to use the bilateral code as two separate line items on a claim, some will say something else. You practically have to have a cheat-sheet that says "Use this if billing Tricare, use this for billing United Healthcare..." etc. etc.

I always try to use the AMA's references since they are responsible for the CPT book. They also have a handy publication that comes out each month called the "CPT Assistant" which gives invaluable examples (in layman's terms) on the correct use of codes and modifiers. But again, you need to be aware of what your payers want when claims are submitted.  Another great coding reference is a book by Ingenix called the "Coder's Desk Reference" which lists all CPT codes and a "layman's" description of what's done by the physician - great for interpreting op reports and other medical procedures that give you an understandable description of the CPT codes. Just my two and a half cents worth!