Proper Usage of Modifier 59

The HHS Office of Inspector General (OIG) found that there is an enormous amount of claims in which modifier 59 is being misused. The misuse is completely unintentional and is largely due to the confusion this modifier causes with many practices when the medical coding is being generated. A random sample of 350 code pairings of samples was taken by the OIG. These random samples were ones that had bypassed the NCCI (National Correct Coding Initiative) edits by using the modifier 59.

The OIG also found that about 40 percent of the code pairs they examined didn’t meet the requirements of the program. This translates to roughly $59 million dollars in incorrect payments made. The report also states that 25 percent of the code pairs were not properly documented and 15 percent were not distinct enough from each other.

The study went on to find that Medicare reimbursed 11 percent of the code pairs even when the provider billed the modifier 59 to the wrong code. This errors in billing amounted to a staggering $27 million dollars. It states that the providers should append the modifier to the lesser service in the NCCI code pair. Furthermore, improper usage of 59 also resulted in reimbursements that were only partially reimbursed.

Make sure you are getting the proper documentation for your medical billing claims and the best way to do that is to outsource your medical billing to the pros that make it their business to always use the proper coding and get your practice the maximum reimbursements possible.

View all Articles by: Melissa Clark, CCS-P