“I am part of a recovery audit from CMS for using a modifier 59. Cotiviti Healthcare has been hired by CMS to review my use of modifier 59. They stated that my operative report supports documented Charcot reconstruction and the use of application of external fixator (CPT 20692) but modifier 59 was inappropriately used since both procedures were performed at the same session. Should I have used a different modifier in this situation? Is application of an external fixator (CPT 20692) not considered a separate procedure if it is performed at the same session as other reconstruction procedures?"
There are a number of recovery audits being performed by CMS as we move into calendar year 2022. The federal government, through CMS, provided a large amount of financial support to providers as the Public Health Emergency, Covid-19 progressed through calendar year 2020. A large portion of these funds did not have to be reimbursed to CMS. Did you really think that CMS was not going to devise a plan to recoup as much of the money as possible?
The above post relates to the 59 modifier being used incorrectly. The number two reason that podiatrists are audited and fail the audit is the inappropriate use of the 59 modifier. This is only surpassed by the inappropriate use of the 25 modifier. Based upon this premise, it is important to look at the definition/description of the 59 modifier.
1. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.
2. Documentation must support a different session, different surgery or procedure, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
3. However, when another established modifier is appropriate it should be used rather than modifier 59. Thus, the physician or his/her designated appointee, the biller or the coder need to perform a modifier search to determine whether or not there is another modifier that should be used in lieu of the 59 modifier. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. In reality, modifier 59 is not the modifier of first choice, rather it is the modifier of last resort.
The issue in the above post relates to the alleged inappropriate use of the 59 modifier with respect to CPT code 20692 which is defined as the following: Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg. Ilizarov, Monticelli type). The operative reports in question support documented Charcot reconstruction and the application of an external fixator designated and billed using CPT code 20692. The 59 modifier was used inappropriately since both procedures, the Charcot reconstruction and the application of the external fixator were performed at the same session.
The performance of both procedures at the same session can, per the definition of the 59 modifier qualify for an inappropriate use of the 59 modifier. However, there are certainly other situations where multiple procedures are performed at the same session and the use of the 59 modifier would be classified as appropriate. I feel that based upon the fact that both procedures were essentially performed at the same anatomical site, this would be a better indicator as to whether or not the 59 modifier was used correctly or not. In order to make this determination, the NCCI edits need to be accessed in order to see whether or not the two procedures in question are bundled. CPT code 20692 would be the Column 2 code. Obviously, we would need to know what the primary procedure/CPT code is based upon the Charcot reconstruction. However, I would suspect that whatever the CPT/procedure code is, it will be the Column 1 code to CPT code 20692, the Column 2 code and that is why CMS’s opinion is that the 59 modifier was inappropriately appended to CPT code 20692. There is not another modifier that can or should be used. CPT code 20692 is considered to be an integral part of the primary procedure, the Charcot reconstruction.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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