The following examples show when modifier -59 should be used in accordance with CPT definition; a coding rule has to be met to report a code combination, and modifiers -51 or -50 will not appropriately explain the scenario.
1. A patient is in the office for an infusion, and after 35 minutes and 200 mg of infliximab, the patient has an adverse reaction. The infusion is stopped, and the patient’s IV is flushed with saline for 32 minutes, and diphenhydramine is pushed to counteract the adverse reaction. The infusion is discontinued, and the patient is monitored for 30 minutes. This would be coded as:
- 96413: chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug;
- 96375: each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure); and
- 96361-59: since only one initial code is allowed per session, modifier -59 will have to be appended to allow reimbursement for the hydration. Usually, the hydration would be bundled with the main procedure, but it is allowed if the saline is used to flush the line in the case of an adverse reaction.
>> With the new -X modifiers, this visit would be billed as follows:
- 96413;
- 96375; and
- 96361-XU: Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service.
2. A 55-year-old female patient with rheumatoid arthritis is seen in the office for a follow-up visit. During the visit, the patient complains of severe swelling and pain in her right shoulder as well as her left knee. The rheumatologist performs a Level 3 office visit and injects the right shoulder and the left knee joint on the same day. (Both procedures are defined by CPT code 20610.) How would this be coded?
- 99213-25: outpatient office visit with a detailed examination and medical decision making with moderate complexity;
- 20610-RT: aspiration of the right shoulder; and
- 20610-59/LT: injection of the left knee.
Modifier -59 is the correct modifier to use because it not only indicates a separate site, but also meets the rule, “when a more descriptive modifier will not explain the circumstances, then modifier -59 is used.”
>> With the new -X modifiers, this visit would be billed as follows:
- 99213-25;
- 20610-RT; and
- 20610-XS: Separate Structure: a service that is distinct because it was performed on a separate organ/structure.
Keep in mind for the joint injection that this will not have any effect on when a physician performs a joint injection to a major joint (20610) and a joint injection to an intermediate joint (20605) during the same session. By definition, these two codes are standalone codes; their descriptions identify them as two separate anatomic locations and no specific coding rules must be met (other than documentation and medical necessity), and both are subject to the multiple procedure payment reduction.
Next Steps
Inaccurate or inappropriate use of modifier -59 can and has generated overpayments, incorrect coding and increased audits. As a reminder, modifier -59 should be used only if no other modifier more appropriately describes the relationship(s) of the two or more procedure codes. It’s vital for rheumatology practices to take time to review their coding to ensure they use one of the more descriptive -X modifiers when it is required. If it is necessary to use modifier -59, there will need to be clear and concise documentation to properly reflect that modifier -59 is being used appropriately. Also, these new -X modifier requirements are from CMS, and there is no indication if they will be accepted by commercial payers.
