“You got to know when to hold ’em, know when to fold ’em.” The use of procedural modifiers is like that old country song: There are times when you should use modifiers and times when you should not.
There are two main sets of rules to know in order to be appropriately paid for procedures, and, according to the rules, anything from a 10000 CPT code through the 69999 CPT codes are procedures. Obviously, this includes all urologic surgical procedures in the 50000 series. This is an area in which the physician has to be knowledgeable in order to:
- document exactly the procedures provided
- accurately convey all services to the biller
- effectively bill for services
Unfortunately, some urologists prefer to remain uninvolved with the coding process and leave it to the billing specialist, ensuring the most inefficient and ineffective billing for services. Show us a urologist who says, “I don’t do coding; I leave that to my assistants,” and we will show you a urologist who is not collecting all that he/she should collect and may be billing for services that should not be billed. This article provides an overview of the coding process, then discusses when to add the appropriate modifier and when it is incorrect to add a modifier.
In reporting services provided to patients, always start by identifying the CPT code(s) describing the service(s) provided during the encounter. Be careful in considering the definition of the CPT procedure code as written. For example, there is no code in CPT for cystoprostatectomy or radical cystectomy, but there are codes for cystectomy with and without lymphadenectomy and with different types of neobladders. There are also codes for cystectomy without neobladder and separate codes for creation of neobladders. CPT convention requires that the patient encounter coding be determined by the most comprehensive code available in the CPT manual.
Bundling vs. global rules
There are two sets of rules that must be understood in order to bill accurately for surgical procedures: bundling rules and global payment rules. The rules are totally separate, and the modifiers used are different.
Bundling, in theory, is the process of including all integral parts or components of a procedure in the payment for a single CPT code. Bundling applies only to a single patient episode of care.
“Global” is the process of a packaging the preoperative care, the surgery, and the postoperative care for a defined period of time into a single payment. Global payment rules will be discussed in a future article.
In billing, unfortunately, the two sets of rules overlap in some situations. When you bill for a service, a computer determines how to pay you, and computers are not programmed for episodes of care. They are programmed to pay based on a “calendar day.” Therefore, the computer will apply the bundling rules to all services provided on the same calendar day.
The concept of bundled procedures is a valid one. If you are being paid to perform a radical cystectomy, you should not be paid for the opening and closing of the wound, mobilization of the bladder, removal of the distal ureters, etc. However, if during the same operation, you performed another, unrelated surgical procedure, you should be paid. Because it is not possible to program a computer for an episode of care, the bundling rules are applied to all patient services provided on the same date, even if they are provided at another patient encounter.
Bundling modifiers
Modifiers were created for the physician to communicate to the computer, previously programmed not to pay for the second service, that the second service or procedure was not an integral part of the main procedure or was not performed at the same time as the main procedure.
Any time two CPT codes are provided during the same patient encounter, you should ask yourself: Is the lesser procedure a component of or an integral part of the more major procedure? If the answer is yes, go no further. Do not charge for the lesser procedure, even if the bundling edits indicate that you can charge for it. If one is an integral part or a component of the other, do not charge for it. On the other hand, if the answer to the question is no, meaning the lesser procedure is not a component or an integral part of the more major procedure, then you should bill for it.
Once the decision to charge for both procedures has been made, consult the bundling edits to see whether the bundling rules have included the lesser procedure in the bigger procedure. If it is not bundled, then bill it to Medicare with no modifier. For private payers, append the –51 modifier to the lesser-valued procedures. This will alert the payer to the fact that this was the lesser procedure. The –51 modifier will not remove a procedure from a bundle.
If the available bundling edits or payer experience indicate that the two procedures are bundled, but can be unbundled with the appropriate modifier, bill the procedure with the most appropriate modifier, such as modifier –59, –Lt, or –Rt. Medicare will pay you if you have the –59 modifier attached to a procedure that the bundling edits indicate can be removed from the bundle with the modifier. Private payers are less predictable; some follow Medicare guidelines; many do not.
However, if the bundling edits indicate that the procedure cannot be unbundled with a modifier and the documentation supports the service as having been performed and it is clearly not an integral part of the service, you may still report the service with the appropriate modifier. For Medicare, the computer will always deny payment based on the Correct Coding Initiative bundling edit, so you must monitor closely and appeal the denial. Private payers should also be monitored closely and appealed, if necessary.
The main modifier that will communicate to the payer that one procedure is not a component of or an integral part of another procedure and should be paid separately is the –59 modifier. By definition, modifier –59 is a distinct procedural service, and according to CPT, it is to be used to identify procedures or services that are not normally reported together, but are appropriate under these circumstances. At times, a procedure may be a component of the primary procedure, but in this particular instance, by applying the –59 modifier, you are saying things are different.
The –59 modifier, like most modifiers, has more than one definition and more than one use. If, by chance, you were doing a procedure on a different site or part of the body, the –59 modifier also would be appropriate. However, in urology, –Lt and –Rt will be more accurate to take us out of that “different part of the body” status in most cases.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Mark Painter is CEO of PRS Urology SC in Denver.
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
