Q&A Proper usage of the -59 modifier

[Brooke_STAT]

If two procedures are considered inclusive per CCI edits, in this particular case CPT 26442 and 26525 for the -59 be justifiable if both procedures were performed in the same finger but (assuming) separate incisions? Our doctor is adamant he should be reimbursed for both and therefore continues to be them together. To further complicate things the 26442 has higher RVU's the the 26525 is considered as the primary procedure. Therefore insurance has denied CPT 26442 billed at a frequency of 2 and paid the 26525. Is this an appealable issue or incorrect billing?

 

[Laureen]

If the work is done on the same finger then it seems they are bundled and you should just report the 26442. If they are done on separate fingers even on the same finger I'd say you could report the 26525 with 59 or with the appropriate HCPCS modifiers that indicate specific fingers.

According to the April 2002 CPT Assistant, coders need not report 26525 (Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint) separately, since 26445 includes the capsulectomy. You asked about 26442 but I think this is where it comes from.

26442 - Tenolysis, flexor tendon; palm AND finger, each tendon
Tenolysis of a single flexor tendon in the palm or finger is performed to restore hand and/or finger motion by releasing scar tissue that has resulted from trauma or a disease process. An incision is made over the affected flexor tendon. Soft tissues are dissected. In 26442, adhesions are severed along the entire length of the tendon in the palm and finger. These codes are reported for each separate tendon treated by tenolysis.

26525 - Capsulectomy or capsulotomy; interphalangeal joint, each joint
Capsulectomy or capsulotomy is performed to relieve extension or flexion contracture in the metacarpophalangeal (MCP) or interphalangeal (IP) joint due to disease, burn, or other injury.

In 26525, a contracture of the IP joint is treated. For a dorsal capsulotomy or capsulectomy, a curvilinear incision is made over the dorsal aspect of the affected IP joint. The ligaments on both sides of the joint are divided. The retinaculum is divided adjacent to the lateral bands. A portion of the collateral ligament is excised. The collateral ligament is freed from the joint margin. The joint capsule is incised and/or a portion excised as needed to improve range of motion. The volar recess is re-established, the retinaculum repaired and the joint pinned in the desired degree of flexion. For a flexion contracture, lateral incisions are made over both sides of the affected IP joint. The volar retinaculum is excised along with the attachment to the flexor sheath. The fibrous portion of the volar plate is incised and the flexor sheath divided. The joint is pinned in full extension. Report for each IP joint treated with capsulotomy or capsulectomy.

 

[Brooke_STAT]

Thank you, but it allows the -59 modifier (when appropriate), would a separate incision on the same finger be appropriate?

 

[Laureen]

I wouldn't be comfortable with that. I'd also need to have the full report before giving any advice that one would be relying on.

 

[Brooke_STAT]

Thank you, I feel the same way. I will send you the link tomorrow when I'm in the office

 

[Brooke_STAT]

I apologize if I'm asking to many questions. Our client is an on-call emergency hand surgeon (that does not participate with any insurance) with patient claims averaging 100,000 to 300,000. That being said, almost every claim is a battle to get paid. However, because he is so adamant about getting reimbursed for both these procedures I was hoping to find something in writing to show him that he cannot bill these codes together. The fact that the 26442 allows the -59 modifier when billed with the capsulectomy opens a door of possibilities. I don't want to continue to appeal something if it is in fact incorrect coding nor do I want to tell the doctor he is wrong if I don't have proof.