ED Coding and Reimbursement Alert

Question: Using the Resource-Based Relative Value Scale (RBRVS), what are the relative value units (RVUs) for modifiers 25, 26, 51, 52, 57, 59, and 80?

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Answer: The official RBRVS as listed in the Medicare Physician Fee Schedule each year assigns no RVUs to any modified code — except for modifier 26 (Professional component) and modifier TC (Technical component). Remember, RVUs simply represent the procedure’s value. Any discounting based on modifiers is subject to individual payer policy.

Once you calculate your location’s allowable, you can calculate the Medicare reduction for modifier 80 (Assistant surgeon) or modifier 51 (Multiple procedures). Under Medicare rules, a surgical assistant is paid 16 percent of the allowable, while the normal multiple procedure reduction is 50 percent of the allowable for the second through fifth additional procedure. Your payer may or may not reimburse a sixth additional procedure.

You won’t have any reduction for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or modifier 57 (Decision for surgery). Why: The payer will decide to either pay the E/M service or deny it.

Also, you cannot calculate the reduction for modifier 52 (Reduced services). Why: The payer will decide your reimbursement based on your ob-gyn’s description of the work she did not perform.