Colonoscopy with Modifier 59

Reimbursement Policy:
Colonoscopy with Modifier 59

Effective Date:
September 1, 2015

Last Revised Date:
May 29, 2015

Purpose:
To provide complete, up-to-date guidelines for the reimbursement of colonoscopy procedures billed with modifier 59. A complete listing of the Relevant Colonoscopy Procedure Codes is included below.

Scope:
All products are included, except products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap). All Insured and ASO accounts are included.

Policy: 
Correct coding rules are followed by Horizon BCBSNJ for the code pairs listed below and have been applied to all Relevant Colonoscopy Procedure Codes (including those codes added, deleted and/or modified by the AMA as of January 1, 2016) as described below:

• 45378 will be denied when billed with codes 45380-45389 if submitted without Modifier 59.

• 45378 will be denied when billed with codes 45380-45386 even when submitted with Modifier 59

• The following code pairs when billed together will result in the first listed code being considered for reimbursement and the second code being denied when submitted without Modifier 59:

This policy also addresses eliminated CPT codes 45383, 45387 and added CPT codes added 45388, 45389 as follows:

• Horizon BCBSNJ will not recognize the application of Modifier 59 when applied to colonoscopy services CPT 45378 when performed with colonoscopy services CPT codes 45388 or 45389 on the same date of service for the same patient by the same provider.
• Additionally, Horizon BCBSNJ will not recognize the application of Modifier 59 when applied to colonoscopy services CPT code 45386, when performed with colonoscopy service CPT code 45389 for the same date of service, same patient, by the same provider in accordance with CPT guidelines. CPT Code 45386 is considered incidental to CPT Code 45389.

Horizon BCBSNJ will continue to recognize Modifier 59 when billed in conjunction with 45386 and 45388. However, based on CPT guidelines, 45386 should not be reported with 45388 for the same lesion, since in that context CPT Code 45386 is considered incidental to CPT Code 45388. Modifier 59 should be reported only when 45386 is billed in conjunction with 45388 for a different lesion. Medical record documentation should support that there were different lesions. CPT defines Modifier 59 as the modifier of last resort which should not be used when a more descriptive modifier is available. With the creation of the additional X{EPSU} modifiers, billers should consider these in lieu of Modifier 59 when appropriate. Horizon BCBSNJ’s systems are currently programmed and recognize these X Modifiers, and therefore, billers should use these instead of Modifier 59 when appropriate.

Horizon BCBSNJ reserves the right and will continue to conduct audits on those providers whose billing pattern around Modifier 59 and/or any other payment override modifier is aberrant compared to like specialty peer group. Billers should continue to ensure medical records are appropriately documented to support the use of Modifier 59 in accordance with OIG recommendations.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure
Do not recognize the application of Modifier 59 for colonoscopy services CPT code 45378 when billed together with colonoscopy services CPT code 45388 or 45389 for the same date of service, same patient, by the same provider.

Do not recognize the application of Modifier 59 for colonoscopy services CPT code 45386 when billed together with colonoscopy service CPT code 45389 for the same date of service, same patient, by the same provider.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

Relevant Colonoscopy Procedure Codes:
45378
45380
45381
45382
45384
45385
45386
45388
45389

Policy 081_v2.0_09212016