Biomaterial Database

When is it appropriate to bill physician services using modifier -59? 2005

Marilyn Hammon

University of Oklahoma Health Science Center, Oklahoma City, USA.

Accurate coding of medical services is a constant challenge for physicians and could jeopardize a practice if not taken seriously. Insurance carriers use sophisticated claims-processing software that easily identifies coding trends by physicians and flags outliers within specialties. The Office of Inspector General (OIG) and the Center for Medicare and Medicaid Services (CMS) hire auditors to identify areas for review which are commonly miscoded. One area that has been flagged for review is billing with modifier -59 because misuse of this modifier has increased inappropriate reimbursement. Be cautious when using this modifier, due to the legal and compliance ramifications when documentation does not adequately support the "distinct procedural service" to justify the use of modifier -59.

UI	MeSH Term	Description	Entries
D005607	Fraud	Exploitation through misrepresentation of the facts or concealment of the purposes of the exploiter.	Fraud, Health Care,Health Care Fraud,Kickbacks,Drug Counterfeiting,Healthcare Fraud,Counterfeiting, Drug,Fraud, Healthcare,Health Care Frauds,Kickback
D006278	Medicare	Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)	Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D039702	Current Procedural Terminology	Descriptive terms and identifying codes for reporting medical services and procedures performed by PHYSICIANS. It is produced by the AMERICAN MEDICAL ASSOCIATION and used in insurance claim reporting for MEDICARE; MEDICAID; and private health insurance programs (From CPT 2002).	CPT Code,CPT Codes,Current Procedural Terminology Code,Current Procedural Terminology Codes,Code, CPT,Codes, CPT