Reminder: Appropriate use of modifier 59 for Medicare Plus Blue claims

As a reminder, follow the guidelines communicated in the September 2021 Record article when appending modifier 59 on Medicare Plus Blue℠ claims. We have begun editing claim lines when modifier 59 is appended on Medicare Plus Blue claims.

This change aligns with the Centers for Medicare & Medicaid National Correct Coding Initiative, or NCCI, program to ensure the correct coding of services. Modifier 59 is used to indicate that a procedure or service was distinct or independent from other services that aren’t normally reported together but are performed on the same day.

We no longer automatically allow payment for certain procedures billed with modifier 59 and related “X” modifiers when billed with a procedure code on the CMS Procedure to Procedure NCCI List. Only select codes allow modifier 59 to automatically bypass the NCCI code-pair edits.

The additional review assures claims have been coded correctly for more complex situations where an overriding modifier has been appended. Health care providers should code claims to the level of specificity for the services rendered and appropriately append diagnosis codes and modifiers following the guidelines published by the American Medical Association and CMS. The reported services should be supported in the patient’s medical record.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation. Also, continue to fax one appeal at a time to avoid processing delays.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.