Claim Editing for Modifier 59
“The Centers for Medicare & Medicaid Services has established code pairs that identify procedure codes that are either mutually exclusive or incidental to one another, or that shouldn’t be reported together due to an overlap in services. [They] currently use the National Correct Coding Initiative, or NCCI, list as published by CMS,” (BCBS, 2021). When in line with Medicare Plus Blue claims, BCBS will begin editing claims that have a 59-modifier attached. The list from NCCI establishes whether or not a 59-modifier can be applied to allow two opposing codes to be billed together and accepted. Along with changes for Medicare Plus Blue claims, changes surrounding the 59-modifier will impact Medicare Advantage PPO claims as well. These changes will promote appropriate use of this modifier to prevent any inaccuracy when billing. Modifier 59 is used when services are performed on the same day that aren’t normally reported together. This code separates the two services as two billable codes. Please see the attached articles for more information and specific scenarios, as well as guidelines to follow when billing in the future.
Sources:
“Claim Editing Update for Modifier 59 Coming Later This Year to MEDICARE PLUS Blue Claims.” The
Record,www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/sep/ ecord_0921v.shtml.
“Claim Editing Update Coming This Year to Medicare Advantage Ppo Claims with Modifier 59.” The
Record,www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/aug/
ecord_0821r.shtml.