Modifier 59 or not for Medicare? - KarenZupko&Associates, Inc.

March 16, 2017

Question:
I am confused how to submit the following code combination to Medicare. The surgeon documented a right shoulder injection with US guidance (CPT code 20611) and a left knee injection without US guidance (20610). I know the codes are inclusive to each other and want to make sure I submit the claim correctly. I am sometimes confused when I should use modifier 59 and wonder if this is a situation where the modifier 59 is the most specific modifier.

Answer:
You are not alone in being confused about when to use Modifier 59 to Medicare and when another more specific modifier would be appropriate. Let’s take a look at a few modifiers and see if we can narrow the spectrum of options with some rationale.

Modifier 50 — Bilateral Procedures: This modifier is not a correct option because the exact same procedure was not performed on the exact contralateral joint.

Modifier 76 — Repeat Procedures by the Same Physician: This modifier is not a correct option because the same CPT code is not reported twice (according to Medicare) during the same face-to-face encounter or on the same date

Modifier 59 — Distinct Procedures: This modifier is an option but according to Medicare carriers, there are more specific modifiers that can be used to describe the distinctness of the procedures and avoid the use of modifier 59.

So what modifiers are more specific?
The more specific modifiers are the anatomic modifiers: RT (right) and LT (left). The goal is to avoid using modifier 59 if a more specific modifier exists. In this case, according to Medicare the RT/LT modifiers are more specific and offset the need to use modifier 59.

Report the following CPT codes on the claim form linked to the associated accurate diagnosis:

20611 RT linked to a shoulder diagnosis
20610 LT linked to a knee diagnosis

This minimizes using modifier 59 to Medicare, and at the same time, accurately reflects the procedures were performed at different anatomic sites.

NOTE: The anatomic modifiers would have also been the most specific if the two injections had been given to both shoulders; one with US guidance and one without US guidance. The codes would be submitted as follows:

20611 RT linked to a shoulder diagnosis
20610 LT linked to a shoulder diagnosis

*This response is based on the best information available as of 03/16/17.