Modifier 59: Don’t Stop! Yield and Investigate

A quick check of the NCCI PTP edits can pay off in a big way.

Let’s say you’re cruising along in what I call the “coding world.” You’re using your bundling matrix software and come across two codes that have a National Correct Coding Initiative (NCCI) edit bundling them (one code includes the other). What do you do? Drop one code and only bill the primary procedure? No! You yield on the coding and investigate the relationship between the two codes. What coders have been taught is that modifier 59 Distinct procedural service should only be applied to a secondary procedure when it follows the “separate” rule (e.g., separate incision, area, organ, etc.). However, the NCCI Policy Manual (great reading) gives us some exceptions to that rule.

When to Yield

Orthopedic coding is a great example. Let’s take CPT® codes 24305 Tendon lengthening, upper arm or elbow, each tendon and 64718 Neuroplasty and/or transposition; ulnar nerve at elbow. You run these codes through your software and there is a bundling issue; however, it does note “unbundling allowed with appropriate modifier.” You need to yield at this point; it is time to investigate.

You turn to your specialty society information (the American Academy of Orthopaedic Surgeons uses Code-X/Global Service Data) and pull up the information for both codes, but no specific information is available under “services not included.”

At this point, you should look for any other specific information in the NCCI Policy Manual. In the narrative for Chapter 4, pages IV-21 and 22 (revision date, Medicare 1/1/2021), it states, “If a provider performs the tendon lengthening described by CPT 24305 and performs an ulnar nerve transposition 64718, the NCCI PTP [procedure to procedure] edit may be bypassed by appending modifier 59 or XU to either column code.”

There you have it! After investigation, the NCCI narrative tells you it is OK to bill these two codes with modifier 59 appended. You aren’t just slapping a modifier 59 on there as a “pay me” modifier; you’ve investigated and have the backup to code and, if necessary, appeal a denied claim with that code combination.

Look for the Right of Way

Another issue with orthopedic coding and bundling comes up with arthroscopic shoulder procedures. This area has been a coder’s nightmare for years with CPT® 29823 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) becoming the “bad guy” with modifier 59.

In 2017 (revision date 1/1/2017), the Centers for Medicare & Medicaid Services updated the NCCI Policy Manual to indicate that 29823 was allowed when coded with other arthroscopic procedures on the ipsilateral shoulder.

The revision gave leeway to the shoulder having “separate/different areas” and indicated that debridement “performed in a different area of the same shoulder” may be reported separately, with three exceptions: 29824, 29827, and 29828. At that point, these code combinations were removed from bundling software and coders had a green light to proceed.

This doesn’t mean that you should always code 29823 with an arthroscopic rotator cuff repair (29827) or a biceps tenodesis (29828). But if your surgeon is performing debridement of the labrum, another separate tendon, or chondroplasty of glenoid/humeral head, you should investigate, regardless of the lack of an NCCI edit. Especially since, effective January 1, the description for CPT® 29823 is revised considerably.

Pass Go and Collect

Don’t be afraid! Yield and investigate the possibility of using modifier 59 to unbundle a code pair. A short investigation could result in a higher reimbursement for your surgeon.

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