ED Coding and Reimbursement Alert

Remember to attach modifier 51 to lower-valued code

ED physicians often have to perform more than one surgical procedure during the same encounter. When this occurs, you-ll likely need to include modifier 59 (Distinct procedural service) or 51 (Multiple procedures) on your claim to show the insurer you aren't trying to overcode the encounter.


You-ll See Modifier 59 Often in ED

Coders must be comfortable using modifier 59 in their coding because the modifier is used so often in the fast-paced ED, says Dawne Beckley, RHIT, CPC, consultant with The Rybar Group Inc. in Fenton, Mich.

In a nutshell: Coders use modifier 59 to identify procedures that are not typically reported together on the same claim but are reportable under certain circumstances, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. Falbo further explains that modifier 59 might be appropriate when your ED physician:

- performs separate procedures at a different session or patient encounter

- performs two different procedures or surgeries

- performs two different procedures or surgeries on different sites or organ systems

- performs separate incisions and excisions on separate lesions

- performs procedures on separate injuries not typically performed on the same day by the same physician.

Consider this example: A multiple-trauma patient presents to the ED and requires both placement of a central line for rapid administration of fluid and a chest tube for treatment of a pneumothorax. In this instance, the ED physician performs multiple procedures involving different sites and organ systems.


On the claim, you should:

- report 32020 (Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]) for the chest tube placement.

- report 36556 (Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older) for the central line placement.

- append modifier 59 to 36556 to show that it was a fully distinct service from the chest tube placement.


Note: Many payers will want to see modifier 59 on the above claim, but some insurers may not want to see any modifiers at all on the claim. If you have any doubt about whether you need the modifier on a claim, check with the insurer. 
 
You-ll Need Modifier 51 on Some Multiple-Surgery Claims

While you-ll use modifier 59 to separate distinct procedures, modifier 51 has a slightly different purpose, Falbo says.

-Use modifier 51 on procedures that are considered components of or incidental to a primary procedure. These are multiple procedures performed at the same session by the same provider,- she says.

Modifier 51 might be appropriate if a patient is seen twice in one day and the physician performs different procedures. More commonly, however, you-ll use modifier 51 when a patient has multiple injuries requiring multiple related procedures during the same session.

Example: A patient involved in an auto accident reports to the ED with cuts to his face in two areas. He has a deep 3-cm laceration on the left side of his face requiring a layered closure, and also a 2-cm more superficial laceration across the bridge of his nose, which is closed in a single layer.

During the encounter, the ED physician is able to treat both wounds by prepping and draping a single surgical field. On this claim, modifier 51 may be appropriate.


On the claim:

- report 12052 (Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm) for the intermediate repair of the face

- report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) for the simple repair of the nasal laceration.

- append modifier 51 to 12011 to show that the repairs were separate.


Reimbursement Suffers When You Put Modifier 51 on Higher-Valued Code

As with modifier 59, many payers will want to see modifier 51 on the above claim, but some insurers may not want to see any modifiers at all on the claim.

If you have any doubt about whether you need the modifier on a claim, check with the insurer.

Don't forget: Attach modifier 51 to the lowest-valued code you are reporting, Falbo says. Do this because the insurer will pay the modified code at 50 percent, and will pay full price for the non-modified code, she says.