NCCI Manual includes clarifications for modifier -59 usage, injections and infusions

January 11, 2016

Medicare Insider

By Steven Andrews

With the latest edition of the NCCI Manual, effective January 1, CMS does not introduce any new guidance for recurring coding trouble areas including modifier -59 (distinct procedural service) usage and injection and infusion services, but some new clarifications could aid coding departments.

The manual now includes new information regarding modifier -59 use for procedures performed at the same patient encounter. The expanded example for timed services, with 2016 additions bolded, now says:

There is an appropriate use for modifier -59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two separate and distinct timed services are provided in separate and distinct time blocks, modifier -59 may be used to identify the services. The separate and distinct time blocks for the two services may be sequential to one another or split. When the two services are split, the time block for one service may be followed by a time block for the second service followed by another time block for the first service. All Medicare rules for reporting timed services are applicable. For example, the total time is calculated for all related timed services performed. The number of reportable units of service is based on the total time, and these units of service are allocated between the HCPCS/CPT codes for the individual services performed. The physician is not permitted to perform multiple services, each for the minimal reportable time, and report each of these as separate units of service. (e.g., A physician or therapist performs eight minutes of neuromuscular reeducation (CPT code 97112) and eight minutes of therapeutic exercises (CPT code 97110). Since the physician or therapist performed 16 minutes of related timed services, only one unit of service may be reported for one, not each, of these codes.)

CMS also added a new example for describing use of modifier -59 to report procedures performed on different anatomic sites:

The procedure-to-procedure edit with column one CPT code 11055 (paring or cutting of benign hyperkeratotic lesion ...) and column two CPT code 11720 (debridement of nail[s] by any method; 1 to 5) may be bypassed with modifier -59 only if the paring/cutting of a benign hyperkeratotic lesion is performed on a different digit (e.g., toe) than one that has nail debridement. Modifier -59 should not be used to bypass the edit if the two procedures are performed on the same digit.

The manual also include a new example to explain proper coding for infusions involving double lumen catheters:

If both lumina of a double lumen catheter are utilized for infusions of different substances or drugs, only one “initial” infusion CPT code may be reported. The double lumen catheter permits intravenous access through a single vascular site. Thus, it would not be correct to report two “initial” infusion CPT codes, one for each lumen of the catheter.

For more information about changes to the NCCI Manual, see CMS’ website.