Gastroenterology Coding Alert

Question: I am uncertain about when I should use modifier 51? Do some carriers no longer accept it?

California Subscriber

Answer: When your physician treats a patient with multiple injuries requiring multiple procedures, you would include modifier 51 (Multiple procedures) on your claim.

Think of it this way: Modifier 51 is an informational-type modifier for use on the second, third, etc., surgical procedure performed on the same day.

For example, when a gastroenterologist extracts stones, he often uses removal and destruction methods in the same session. This means you may be able to:

• report 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method),

• append modifier 51 to 43264 (... with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts]).

The modifier shows the carrier that the gastroenterologist performed removal and destruction procedures in the same session.

Check with your insurer first: Attaching modifier 51 to 43264 in the above example may not work with all insurers. Many carriers, including Medicare, no longer require modifier 51. Processing claims electronically allows the carrier to recognize when your physician performs multiple procedures and automatically make the necessary reduction in payment.

Make a pre-emptive strike against denials by contacting your insurance carrier and asking the representative which method it would prefer when reporting multiple surgical procedures.

Then, make a note of each payer's policy on coding multiple procedures so you can reference it quickly the next time a modifier 51 issue arises.

Remember: You can expect half the normal reimbursement for codes with modifier 51 attached. (Most insurance companies have adopted Medicare's policy of paying 50 percent for codes with modifier 51 attached.)