Modifier 59 Misuse Cost 1 Health System Millions — Know Where to Go for the Rules

False Claims Act settlement modifier 59

Exploiting modifier 59 was a major factor in a recent $12.5 million settlement for False Claims Act allegations. How’s that for motivation to shore up your modifier 59 know-how? Here are some resources to get you on your way.

Read the Write-Up on the Recent False Claims Act Settlement

Find out some of the details that resulted in the $12.5 million settlement and five years of regular monitoring of billing practices for a hospital and health system in Pennsylvania by reading the brief DOJ release about the case. With modifier 59 (Distinct procedural service) in the mix, you can guess that intentional improper unbundling was a major player. Physician documentation designed to support improper unbundling was another issue, so this may be worth sharing with providers, too.

Get Familiar With the CMS Modifier 59 Article

On Medicare’s National Correct Coding Initiative Edits page, the Downloads section includes “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service.” If you’ve been coding a while, some of the information may not be new to you. But there are some specific examples in there of when it is and is not OK to override CCI edits using modifier 59, and official Medicare examples are always a handy helper to have. There’s also some discussion of those X modifiers that made a big splash a while back but are not yet required by Medicare. The last update was on Nov. 15, 2017, so keep that in mind as you read.

Watch for Mentions of Mod 59 in the CCI Manual

The CCI manual, available on the same CMS page as the Modifier 59 Article, has all sorts of helpful hints for reporting services in line with CCI rules. You can search the PDF for 59 to find mentions of this modifier. For instance, searching chapter 4 for 59 brings up the explanation that spinal fusion exploration code 22830 is not reportable with another code for a spine procedure in the same anatomic area. But if the exploration is in a different anatomic area, you may use modifier 59 to separately report 22830.

Better yet, read all of the sections that apply to you so you get all that good info in one go.

Look Up Local Policies

Individual payers may have their own guides and policies on modifier 59, so don’t miss your chance to learn exactly what your specific payer has to say. Knowing where to locate the policy can be particularly helpful if you have issues with a claim and need to show the payer that you followed their rules.

What About You?

What’s the most helpful official resource you’ve found for helping you decide when to use modifier 59 or another modifier to unbundle codes?






Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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