BUSINESS: coding strategy

Medical Necessity Rules the Day


  coding strategy

Medical Necessity Rules the Day

Stick to the rules, and avoid using modifier -59 out of convenience.


If there is one thing that I am adamant about, it is following the rules, particularly when it comes to medical coding. Whether they work to our benefit or against us, generally there is very little gray area between the black and white of interpreting the rules. That being said, some practitioners appreciate the gray more than the black and white.

This is no more apparent than in the use of modifier -59, a common yet abused and audited modifier.

Mutually exclusive

Modifier -59 has been “targeted” for abuse by the OIG for several years. I bring up this topic because of a 2013 and restated 2014 change in policy regarding the use of OCT and fundus photography.

Performing OCT and fundus photography on the same date of service on the same eye is considered “mutually exclusive,” according to the National Correct Coding Initiative, thus not doable. A mutually exclusive edit comes under the 2014 classification of Procedure-to-Procedure edits, which prevent inappropriate payment of services that should be reported together, and is defined as “procedures that cannot reasonably be performed at the same anatomic site or same patient encounter.”

On the other hand, the 2014 National Correct Coding Initiative Policy Manual For Medicare Services states, “Fundus photography (CPT code 92250) and scanning ophthalmic computerized diagnostic imaging (CPT codes 92132, 92133, 92134) are generally mutually exclusive of one another in that a provider would use one technique or the other to evaluate fundal disease. However, there are a limited number of clinical conditions where both techniques are medically reasonable and necessary on the ipsilateral eye. In these situations, both CPT codes may be reported appending modifier -59 to CPT code 92250.”

Modifier -59 Definition and Context

Modifier -59’s definition is very specific and should not be taken lightly:

Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.”

It is generally used as a modifier of last resort when no other modifier fits the definition of the situation at hand. NCCI policy specifically states to use modifier -59, so a reference exists if a claim gets called into question.

Thus, the “gray,” which creates the opportunity for abuse.

Risk vs. reward

Due to this rule change in this rule, I fear everyone will start doing these procedures on the same date of service “just because they can.” If there is proper medical necessity established in the medical record that clearly states that it is in the patient’s best medical interest to have those procedure performed on the same day, then the modifier -59 exception can come into play. It shouldn’t be for the patients’ convenience or just because the doctor wanted to.

This explains why glaucoma is not generally included in the list of specific covered diagnoses that the LCDs allow to be performed on the same day — it is not deemed to be an emergent condition that requires the procedures to be performed simultaneously. Exceptions are generally limited to retinal conditions.

It is my opinion that if proper medical necessity is established in the record and that it was done because of the best medical outcome for the patient, the doctors’ record would stand in an audit.

The bottom line

The -59 modifier may attract attention at the carrier level, and its use should be rare. But the medical record should stand on its own if the doctor follows the rules and principles outlined in the federal publication.

Also, CCI edits are federal rules and not overruled by local carriers.

While I am the first to admit that insurance coverage policies and rule sets typically lag the development and utilization of technology in our practices, these are the rules and we must follow them until they are no longer the rules. It is nice when one actually sees progress in practicality as we do in the use of OCT and fundus photography on the same day. However, I would not rush into performing them together until carrier policies are further refined.

Assess each patient on an individual basis, and make sure that your clinical record clearly establishes the medical necessity. After all, no one but you gets the reward…and accepts the risk. OM