Wiki Modifier 59 When to use?

Tara0513

Networker
Messages
55
Location
Colts Neck, NJ
Best answers
0
My billing team has been questioning me if we can use modifier 59 for these two different scenarios, and I am really unsure of the answer. Hoping someone can help me.
Scenario 1: Gastro referring provider takes two specimens during a procedure. The ordering provider sends one of the specimens to our independent lab and sends the second specimen to a completely different lab (I am not sure why he does this), now our claim is being denied as "THIS SERVICE IS NOT PAID. THE PAYMENT FOR THIS SERVICE WAS MADE FOR THE SAME DATE OF SERVICE TO A DIFFERENT PROVIDER". Now can we append modifier 59 on our claim to show that it is different service from the other lab? I am not sure if this is correct coding/billing. Is there any way around this? We have tried to appeal explaining we are a separate lab etc. but it has not worked in our favor.

Scenario 2: Urgent care facility submits a nasal swab to our lab to test for Covid 19, Influenza a&b and RSV. Now with United Healthcare per their policy POS should be where the specimen was obtained (20-urgent care) not POS of where the specimen was processed (81-independent lab) United is now denying our claims for max units reached. The AR department stated that they have submitted corrected claim after appending modifier 59 on our claim and United is processing the claim. They said they even have done this with some Aetna claims as well. Is this the correct way to bill? I just do not know; I do not feel comfortable.

Hoping someone can clarify these two scenarios as to what is the correct way of coding and appealing, and if I am wrong in worrying that using modifier 59 is incorrect.
 
My billing team has been questioning me if we can use modifier 59 for these two different scenarios, and I am really unsure of the answer. Hoping someone can help me.
Scenario 1: Gastro referring provider takes two specimens during a procedure. The ordering provider sends one of the specimens to our independent lab and sends the second specimen to a completely different lab (I am not sure why he does this), now our claim is being denied as "THIS SERVICE IS NOT PAID. THE PAYMENT FOR THIS SERVICE WAS MADE FOR THE SAME DATE OF SERVICE TO A DIFFERENT PROVIDER". Now can we append modifier 59 on our claim to show that it is different service from the other lab? I am not sure if this is correct coding/billing. Is there any way around this? We have tried to appeal explaining we are a separate lab etc. but it has not worked in our favor.

Scenario 2: Urgent care facility submits a nasal swab to our lab to test for Covid 19, Influenza a&b and RSV. Now with United Healthcare per their policy POS should be where the specimen was obtained (20-urgent care) not POS of where the specimen was processed (81-independent lab) United is now denying our claims for max units reached. The AR department stated that they have submitted corrected claim after appending modifier 59 on our claim and United is processing the claim. They said they even have done this with some Aetna claims as well. Is this the correct way to bill? I just do not know; I do not feel comfortable.

Hoping someone can clarify these two scenarios as to what is the correct way of coding and appealing, and if I am wrong in worrying that using modifier 59 is incorrect.
I am absolutely baffled here. I would never utilize a modifier 59 in my pathology career moving forward for years today. Well let's figure out clearly what is happening here!! If you are appealing and your claims are still being denied it is BECAUSE IT IS STILL WRONG. If it is UHC or AETNA well those plans don't play happy with the rest. And Pathology Coders need to "reinvent" the wheel because they are BOTH just incredibly horrible. You think I am lying!! My hubby has their annual recertification for their company's insurance this month and I was ~ oh goodness seriously heck no. I would seriously rather eat dirt than deal with AETNA (cannot make this crap up). I really dislike them. Have you ever dealt with one of their denials (on a phone call).? I will never allow my family the pleasure of dealing with AETNA as long as I live and breathe today.
I don't do labs anymore so need others to step in.
Dana
 
I am absolutely baffled here. I would never utilize a modifier 59 in my pathology career moving forward for years today. Well let's figure out clearly what is happening here!! If you are appealing and your claims are still being denied it is BECAUSE IT IS STILL WRONG. If it is UHC or AETNA well those plans don't play happy with the rest. And Pathology Coders need to "reinvent" the wheel because they are BOTH just incredibly horrible. You think I am lying!! My hubby has their annual recertification for their company's insurance this month and I was ~ oh goodness seriously heck no. I would seriously rather eat dirt than deal with AETNA (cannot make this crap up). I really dislike them. Have you ever dealt with one of their denials (on a phone call).? I will never allow my family the pleasure of dealing with AETNA as long as I live and breathe today.
I don't do labs anymore so need others to step in.
Dana
OMG LOL I am dying laughing. I hate United and Aetna and I currently have Aetna for my own medical health insurance (they are horrible they do not want to pay anything), and I used to have United before Aetna. We have been having major issues with United processing any of our claims. They have been inundating us with medical records requests for almost every claim no matter how straight forward the claim is. But going back to my 2 scenarios I 100% do not agree with using modifier 59 at all. This has been done without my approval, or even asking me. We should be calling the insurance companies, and supposedly someone did call Aetna and they didn't tell the biller that they should not use modifier 59 (even though I have explained the insurance will not tell you how to get your claims paid) and they even reprocessed and paid the claim with the modifier 59. My other issue is that any of the X codes do not apply to these scenarios. I am at a loss as to what needs to be done to appeal these claims correctly. I am a rule follower as all certified coders, but its hard to fight other employees on how to code correctly when they are seeing claims being processed after adding incorrect modifiers. I am really hoping someone helps me out with these issues. As both scenarios we are being punished for things out of our control. We have no control over what specimens the ordering providers sends to our lab vs to another lab from a same date of service procedure. The only thing I can think of is going forward explaining to the ordering provider that all specimens collected from one patient have to be sent to one lab not split up and sent to two different labs.
 

Hello Tara0513,
I am so thankful to have met another specialty coder in these issues! I clearly do not know why one specimen was sent one place (and the other specimen was sent to another place).
I'm not being arrogant. One claim got out the door first. I CLEARLY don't understand the rationale here on why two locations. I just know that if you send two specimens with same DOS that one of them needs a modifier to be billed because it was a repeat specimen in the denial world. Maybe not same doctor but someone else. God Bless!

 

Hello Tara0513,​

I am so thankful to have met another specialty coder in these issues! I clearly do not know why one specimen was sent one place (and the other specimen was sent to another place).

I'm not being arrogant. One claim got out the door first. I CLEARLY don't understand the rationale here on why two locations. I just know that if you send two specimens with same DOS that one of them needs a modifier to be billed because it was a repeat specimen in the denial world. Maybe not same doctor but someone else. God Bless!

No arrogance detected!! I was thinking repeat modifier, but the two specimens are of two different areas of the body during the procedure. Like let's say an EGD was performed, and one is a biopsy of the antrum, and the other is a bx of the esophagus, so I am at a loss....I really appreciate you taking the time out of your day to read my issues and answer me. Thank you!!! I am grateful!
 
Hello Tara0513
I just pulled up the information I use on the X modifiers from CMS.
https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf
I would never ask anyone ever to copy and paste a link unless it was reliable. There is no urgency here. Take your time please. I shared the screen shots to provide my intentions were sincere.
1720576637700.png

If you would rather locate the documentation yourself use "X modifiers CMS" as your personal search engine and you should still get to the link I provided. I provided a screen shot.
1720576411483.png
Those documents may contain other information to determine proper modifier assignment and I was just trying to help you.
Thanks,
Dana
 
Top