How does modifier 59 affect medical billing?

The world of healthcare and medical billing has long been a tricky one. Adding to the confusion for both patients and practitioners is a dreaded phrase: modifier 59, the most misused modifier in medical billing. For years, the code has been a nightmare in the medical billing world. Beyond the headache it causes providers and medical billing coders, it also costs the government millions in improper reimbursements each year.

What exactly is modifier 59?

Modifier 59 is a medical billing term used when two or more procedures are done to the same patient on different parts of the body. The ambiguity of that statement has led to it becoming highly misused among providers. According to reports from the Inspector General of Center for Medicare and Medicaid Services (CMS), more than 40 percent of modifier 59 use has been incorrect this year. An example of this is if there's a procedure on both the nail and tissue surrounding the nail in the same day. These are two distinct and unique procedures on different parts of the body occurring on the same day.

Why has it caused so many problems?

Part of the issue with modifier 59 billing has been the ability for providers to interpret what counts for the modifier. The language related to the modifier is not as clear as other sections of medical billing codes are. These grey areas surrounding what counts for modifier 59 and what doesn't have caused significant problems, leading to multiple rule updates being created to try and deliver clarity. Each passing rule change, however, seems to create further confusion. Current guidance, with the latest changes issued in 2019, now suggests that only providers and coders should add modifier 59 to a bill. With billers now removed from the situation, there's hope for greater accuracy among providers that the modifier will be correctly applied.

What has been done to correct the issues?

To increase accuracy around modifier 59 billing, CMS created new modifiers in 2015 for many of the most common errors that were billed as modifier 59s. Among those are modifiers XE and XS. The different modifiers were supposed to fix problems with common billing errors. Modifier XS, for example, relates solely to functions performed on entirely separate organs, which isn't covered by modifier 59. On the other hand, modifier XE relates to functions performed on the same part of the body on different days. The new modifiers were supposed to clear up the confusion around modifier 59. Instead, the same problems continued to plague the system. Part of the problem was with providers and coders having a misunderstanding related to the differences with the new modifiers. The confusion caused by these changes led providers to use the code they were used to instead of the correct one, failing to solve the problem.

Providers ignore the codes

Following continued guidance changes on modifier 59 use, providers began to use a different tactic. They began to not add any modifiers at all. Even in cases where modifier 59 was the correct code to add, providers would leave it off. This once again caused the error rate to spike. With medical providers now choosing to skip billing modifier 59 in cases where it should be applied, the problems continue for CMS. These issues are hurting the federal government in a significant, and expensive, way.

How much is wasted on modifier 59 misuse?

Issues related to modifier 59 have a bigger impact than paperwork confusion and frustration, however. Improper billing related to modifier 59 codes is responsible for significant waste at CMS. By properly billing these cases and having greater clarity on which modifier applies, the federal government will see significant savings in administrative costs. Eliminating errors will also cut down on frustration facing those using Medicare and Medicaid when dealing with the government. So far in 2019, more than $59 million has been improperly reimbursed through modifier 59 errors. These issues are hurting patients and providers in the Medicare and Medicaid system. The problem has been so pervasive that the government had to once again issue guidance to providers and billers. Despite previous attempts to increase accuracy in modifier 59 billing, more than 40 percent of its use was inaccurate. Why does this continue to happen? Despite many providers and billers knowing what the language for modifier 59 qualifications means, there's a lack of understanding. Making matters worse is the rules issued by CMS, which remain ambiguous and too open to interpretation. An unambiguous update to modifier 59 language can eliminate the problems and create greater clarity for both billers and providers.