General Surgery Coding Alert

Question: I heard a colleague discussing CPT codes that are exempt from modifier 51. How can I find out which CPT codes are modifier 51 exempt?


California Subscriber

Answer: There are several exceptions to modifier 51 (Multiple procedures) in CPT 2006 -- so many, in fact, that the AMA includes separate appendices with a list of all the codes that are exempt.

Specifically, you should never append modifier 51 to designated add-on codes (any code listed with a -+-) or to designated -modifier 51 exempt- codes (identified in CPT by a X next to the code).

For example, 99143 (Moderate sedation services ...; under 5 years of age, first 30 minutes intra-service time) is modifier 51 exempt. To the left of the CPT entry for 99143, you-ll notice the X symbol.

The relative values for these codes already take into account the -additional- nature of the procedure, and, as such, payers should not reduce payment for these procedures further.

Big tip: You can find a full list of add-on and modifier 51 exempt procedures in Appendices D and E of CPT.

Important: Even when -multiple procedure- reductions apply, you usually won't have to append modifier 51. This is because many payers now use software that automatically detects second and subsequent procedures and reimburses them accordingly, thereby making modifier 51 unnecessary.

You should check with your individual payer for its guidelines, however. As always, request the payer's instructions in writing because documentation is your best defense if your billing methods are questioned.