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Modifier 51

Chuck Posted Tue 11th of February, 2014 13:53:07 PM

Sorry if I don't communicate as you would have me do....my first time. I'm sure I'll learn. Here's my question (please see example):

CPT DX
99214 786.05 780.79 296.80 278.00
93000 Same 4
99000 Same 4
36415 Same 4

Do you see a need for modifier 51?
Thanks!
Chuck

SuperCoder Answered Tue 11th of February, 2014 17:33:04 PM

Please confirm with the payor, do they really require Modifier 51 here.

About modifier 51
Modifier 51 (multiple procedures) is used to inform payers that two or more procedures are being reported on the same day. A claim form (CMS 1500) that has modifier 51 appended to a CPT code(s) tells the payer to apply the multiple procedure payment formula to the CPT code(s) linked to the modifier 51, assuming the payer accepts this modifier.

Some payers may not accept or require the use of this modifier because their computer systems are already programmed to automatically apply the multiple procedure reduction to the lesser-valued code(s). It is important to remember the following conditions that apply to the use of modifier 51:

No special rules related to the reporting of the code combinations can apply.
The CPT code(s) cannot be an add-on (CPT Appendix D) or modifier 51 exempt (CPT Appendix E) codes.
The CPT code(s) must be stand-alone procedures and not inclusive to other procedures performed at the same time.
Unless your contract with the payer includes a “carve out,” the subsequent procedure(s) is(are) subject to the payer’s multiple procedure payment formula.

Chuck Posted Wed 12th of February, 2014 10:34:00 AM

No offense, but this is information that is readily available and can be copied and pasted.
I'm in need of your opinion as a coder, please.
One of the reasons that we purchased this program was that we could ask specific coding questions and receive answers that went beyond my expertise as well as what I could locate in a CPT book or user forums on the internet.
Please see my example above and provide your professional opinion with reference to this specific case please.
Forgive me if I seem harsh, I don't mean to come across as unreasonable or unfriendly....
We look forward to your program and services.
Thank you!
Chuck

SuperCoder Answered Wed 12th of February, 2014 17:53:47 PM

Hi Chuck,

Thanks for the concerns and trust bestowed.

Many times, when a physician performs multiple procedures, he does not need to repeat all of the work for the second and subsequent procedures. Modifier 51 (Multiple procedures) recognizes this fact by lowering the reimbursement for subsequent procedures to reflect the fact that less work was performed.

Many payers including most Medicare carriers don’t want you to use modifier 51. The insurer’s software automatically sorts the procedures on your claim in order from highest to lowest relative value units (RVUs). The payer then pays the highest-ranked procedure at 100 percent and any additional surgical procedures at 50 percent. On the other hand, many Medicaid payers still require you to properly apply modifier 51.

And don’t forget only physicians and imaging centers use modifier 51, not hospitals.

This is not a likely scenario for modifier 51 use. Modifier 51 would be more appropriate in case with multiple surgical procedures.

Many payers, including Medicare, prefer that you not use modifier 51 because the payers weight the codes themselves. E.g., see http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-51.shtml

You may need modifier 25 on the E/M depending on your payer. You also should check whether the payer covers the last two codes so you know what to expect in terms of coverage and payment. You also should check the CPT/ICD-9 pairings so each code is paired with the diagnosis that supports its medical necessity.

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