Gastroenterology Coding Alert

Question: Some coders have been telling me that modifier -51 doesnt have to be used to report multiple endoscopies performed during the same session.
Is this true?

Minnesota Subscriber

Answer: Whether modifier -51 (multiple procedures) should be used to report multiple procedures depends on the payer. Both CPT and the Medicare Carriers Manual (MCM) specify that the modifier should be used to report multiple procedures. Your coding associates are also correct, however, that many Medicare carriers no longer require providers to use the modifier on their claim. And some coding experts feel that gastroenterologists may even lose reimbursement dollars by using the modifier.

As a matter of national policy, both CPT and the MCM indicate that modifier -51 should be used to indicate multiple procedures/multiple endoscopies. According to the book Principles of CPT Coding, which is written and published by the American Medical Association, [w]hen multiple procedures, other than Evaluation and Management Services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier -51 to the additional procedure or service code(s)

If the procedures are not in the same family, such as a colonoscopy (45378) and an upper gastrointestinal endoscopy (43235), the multiple procedures payment rule applies. The higher-valued procedure (45378) will be reimbursed at 100 percent of its allowed amount. Modifier -51 should be attached to the lesser-valued procedure (code 43235), and reimbursement will be 50 percent of the procedures allowed amount.

When the endoscopic procedures are in the same family and have the same endoscopic base code, the multiple endoscopies payment rule applies. If, for example, a gastroenterologist performs an upper gastrointestinal endoscopy with biopsy (43239) and inserts a guidewire to dilate the esophagus (43248), modifier -51 would be attached to the lesser-valued procedure (43239). Code 43248 would be reimbursed at 100 percent of its allowed amount. Because the endoscopic base code for both of these procedures is 43235 (upper gastrointestinal endoscopy), reimbursement for the lesser-valued procedure (43239) is the difference between the allowed amounts for 43239 and 43235.

Despite the fact that the MCM indicates that modifier -51 should be used to report multiple procedures, local Medicare carriers are issuing instructions to providers that the modifier is not needed. For example, the April 2000 issue of the Georgia Medicare News reported, Modifier -51 is not required for billing purposes. The carrier will assign the multiple procedure modifier, if appropriate, based on the services billed.

Although most coding experts say that using modifier -51 on Medicare claims is optional and will neither hurt nor help, at least one expert believes that the modifier should never be used. Medicare does not encourage gastroenterologists to put the modifier on, so leave it alone, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. Let the Medicare computer figure it out for you.

According to Callaway, some carriers will apply the multiple procedures deduction twice if modifier -51 is used on a claim. When there are two codes from the same family, the carrier may see the modifier and apply the 50 percent multiple procedures deduction to the lesser-valued procedure, she explains. But then the carriers computer is still programmed to automatically take the difference between the lesser-valued procedure and its base endoscopic code.

Because the reimbursement for multiple endoscopies in the same family is often quite small (less than $20 in the previously cited example with upper gastrointestinal endoscopy with biopsy and the dilation over guidewire), Callaway suspects that some gastroenterologists who continue to use modifier -51 on their claims may be getting the extra deduction and not even know it.

Callaway suggests that gastroenterologists and their coders stop using the modifier and monitor their explanation of benefit (EOB) statements to make sure second procedures are getting paid without the modifier. If they arent, then you should go back to Medicare and talk with them.

Some commercial insurance companies require the use of the modifier, and others do not. You have to watch the commercial insurers, Callaway says. Most of them process the claims without a modifier, but occasionally there is one that requires it. The trend with these payers, however, is to drop it. A quick call to the carrier should be made to get their policy on the use of modifier -51.