Health Information Management

Tip: Correctly assign modifier -59 to override NCCI edits

APCs Insider, April 16, 2010

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Some therapies are considered edited pairs and are not billable on the same date of service unless CPT modifier -59 (distinct procedural service) is appended properly. 

Therapists and coders may overuse it because they don’t understand the definition of separately identifiable. However, not reporting the modifier when it is appropriate will result in bundling of services, leading to a great loss of revenue in your therapy department.
 
First, ensure that your documentation supports the use of modifier -59 to bypass an edit. Then be sure to append the modifier to the correct code. If you affix modifier -59 to both codes, you may be subject to denial of payment for both procedures. Modifier -59 always is appended to the code listed in Column 2. If you affix the modifier to the wrong code, you risk incorrect reimbursement—more or less than what you’d otherwise receive. 
 
This tip is adapted from “Should you override that outpatient therapy NCCI edit?” in the April issue of Briefings on APCs.



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