The Modifier of Last Resort...

The Correct Coding Initiative (CCI) is a program developed by a private company on behalf of The Centers for Medicare and Medicaid Services (CMS) that bundles component services into comprehensive procedures and permits Medicare reimbursement of only the comprehensive code. These edits are designed to prevent:

• Fragmenting one service into component parts and coding each component part as if it were a separate service
• Reporting separate codes for related services when one comprehensive code includes all related services 
• Breaking out (unbundling) bilateral procedures when one code is appropriate
• Downcoding a service in order to use an additional code when one higher level, more comprehensive code is appropriate

There are two sets of Correct Coding Initiative tables, comprehensive /component (correct coding or bundling) edits and mutually exclusive edits . The mutually exclusive edits define circumstances where it would be technically impossible to perform both of the services on the same patient for the same service date and will not commonly occur in radiation oncology coding.

The CCI principle of combining component services into the comprehensive procedure utilizes the following principles:

1. The bundles service represents the standard of care in accomplishing the overall procedure

2. The bundled service is necessary to successfully accomplish the comprehensive procedure; failure to perform the service may compromise the success of the procedure

3. The bundled service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

Modifier -59 has been established to allow separate reimbursement when multiple procedures are performed for the same patient on different anatomical sites, or at different sessions during the same day. The CPT modifier definition is:

"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, sepaate 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."

When multiple patient services are reported by the same physician on the same date of service, there may be a perception of "unbundling " when, in fact, the services were performed under separate and distinct circumstances. Because insurance payors, including Medicare carriers, cannot identify these situations based solely on CPT code assignment the -59 modifier was established to permit unrelated services to bypass correct coding edits. Frequently, another modifier that better describes the particular situation should be used in place of modifier –59. Examples of these modifiers include:

Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.

Modifiers -76/-77 Repeat Procedure by Same/Another Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service.

In addition, each bundled code pair in the CCI is further assigned a modifier indicator of “0”, “1” or “9”. Modifier indicator “0” means that a modifier (such as modifier –59) will not bypass the code combination. Modifier indicator of “9” indicates that the use of modifier is not specified with the code combination listed, and may be open to individual carrier interpretation. A common question concerns the “1” indicator after a code pair that indicates a modifier may be appropriate to bypass the bundling edit. This modifier indicator does not, however, imply that a modifier should be automatically applied every time the codes are both assigned on the same service date.

For example, IMRT planning (77301) bundles a number of other services, such as basic dosimetry calculations (77300). According to the definitions provided, the –59 modifier should not be applied when the calculations are printed as part of the IMRT plan, since these two services are correctly bundled when performed on the same date of service.

The CCI Manual further states: “The –59 modifier is often misused . The two codes in a code pair edit often, by definition, represent different procedures . The provider cannot use the –59 modifier for such an edit based on the two codes being different procedures . However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, the –59 modifier may be appended.”

In summary, practices may want to track the use of modifier -59 and perform random audits of modifier usage to ensure that it is correctly applied, and that documentation supports the separate nature of the services performed.

Reprinted with permission from the Journal of Oncology Management Sept/Oct issue

Cindy C. Parman, CPC, CPC-H
principal and co-founder of Coding Strategies, Inc. in Atlanta, GA. Cindy is a current member of the Advisory Board for the American Academy of Professional Coders (AAPC) and a faculty instructor for AMA Solutions, a subsidiary of the American Medical Association.  She serves as the Consulting Editor of the Radiology Coding Alert and is on the Editorial Advisory Board of General Surgery Coding Alert and Pain Management Coding Alert.  

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