Q. My pain management physician is performing facet injections or epidural transforaminal injections on patients according to coverage guidelines for the patient’s insurer. However, services are continually being denied because the services aren’t modified correctly. Do I need a 59 modifier?

A. Not necessarily. One of the directives to be aware of may be related to the payer’s requirement for modifiers to unilateral or bilateral procedures. Procedures such as transforaminals and facets, as well as facet denervation codes, sacroiliac joint injections and trigger point injections, are considered unilateral in nature. If your physician is performing bilateral injections, place the 50 modifier on the service. But also keep in mind that the payer may be looking for unilateral (RT or LT) modifiers as well.

The 59 modifier may also be appropriate when documentation supports performance of separate procedures that are typically considered bundled due to National Correct Coding Initiative Procedure to Procedure (or other payer bundling) edits. The 59 modifier is used to report that one procedure was distinct or independent from another on the same date of service. Documentation in the patient’s medical record should support a different encounter or session, different body site or organ system, separate incision, lesion or injury. Other modifiers (such as 51) may be more appropriate, and in some cases the 59 modifier may never be allowed in certain coding combinations.

Best policy is to be sure to review individual payer guidelines frequently and alert physicians to the need for review as well.

 

This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of anesthesia and pain management. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.


 

McKesson

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McKesson Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.