For those of you unfamiliar with coding and billing, modifier -59 is a two-digit numeric code modifier that can be appended to a CPT or HCPCS procedure code, for example, and will frequently bypass many payor edits. These edits are typically in place to prevent unbundling and overpaying of services in typical circumstances.
However, as we all know, there are many exceptions in healthcare. Modifier -59 is appropriate when certain clinical circumstances are met to bypass certain edits while ensuring additional reimbursement.
But remember, medical records that describe the appropriateness of such a modifier are not typically submitted in advance with a claim. Medicare and Medicaid, for example pay providers on the trust system since providers are required to certify they will follow all the rules and submit claims appropriately.
Recently, one provider, Mercy Hospital in Portland, ME settled with the government for $1.5 million to resolve allegations that they overbilled Medicare and Medicaid. The chief culprit in these allegations: Modifier -59 (the bad boy of coding).
According to court documents, the government alleged that Mercy inappropriately used modifier -59 from 2011 to 2013 on urinalysis drug screening tests. Specifically, the government asserted that modifier -59 was appended to HCPCS code G0431 on approximately 85% of Medicare and 65% of Medicaid urinalysis tests claims.
HCPCS code G0431 is for “Drug screen, qualitative; multiple drug classes by high complexity test method (for example, immunoassay, enzyme assay), per patient encounter.” In this particular settlement, the key phrase in this code is “per patient encounter.” In other words, this code should only be billed once per patient encounter even if multiple drug classes are tested.
The hospital allegedly billed the code multiple times for multiple tests with modifier -59 even though only one patient encounter took place. Use of modifier -59 is not appropriate in this circumstance. Use of that modifier might be appropriate if it were medically necessary for tests to be performed at different patient encounters on the same date of service for example.
Interestingly, in this case, the government was tipped off by an anonymous caller as opposed to so many headlines we read where a whistleblower files a qui tam lawsuit that can sometimes lead to a share of the financial recoveries. The court documents state that after they received the call they analyzed the provider’s use of modifier -59 in the circumstances described and found them to be an outlier.
You may think this doesn’t apply to your practice or organization if you’re not providing the exact same service described in G0431. However, the concepts and principles of appropriate and inappropriate use of modifier -59 in this case are applicable to thousands of scenarios where modifier -59 might be used.
The National Correct Coding Initiative (NCCI) from CMS describes further the differences between appropriate and inappropriate use of modifier -59. To learn more about the NCCI’s guidance on modifier -59 see this link
The OIG has also performed audits and published reports about modifier -59. For example, their recent Work Plan states they are going to review usage of modifier -59 nationwide as it relates to cardiac catheterizations and endomyocardial biopsies.
If your compliance program has never done an analysis of your billing data for modifier -59 along with an accompanying audit of services where modifier -59 was regularly used, it should probably be near the top of your list for your next round of compliance audits. If you need consulting help with modifier -59 analysis and audits, please feel free to contact me at cj.wolf@healthicity.com.
CJ Wolf
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