General Surgery Coding Alert

Modifier -59 is "used when multiple procedures in the same (code areas) are performed at the same time," says Linda Parks, MA, CPC, CMC, CCP, coding specialist in Marietta, Ga.

Example: Let's take the scenario mentioned earlier, in which the physician performs a hysterectomy and separate abdominal repair in the same session. A 35-year-old patient reports to the office with uterine fibroids and a symptomatic enterocele. The ob-gyn performs a complete abdominal hysterectomy and makes a repair to the enterocele via abdominal approach.

You should:

Remember: The higher the relative value units (RVUs) for a given code, the more you'll be paid for the procedure. Always attach modifier -59 to the code with the lower RVUs.

Payoff: The RVUs for 58150 (hysterectomy) are 24.63 for facilities, while 57270 (abdominal repair) is worth 19.78 for facilities.

If you're stuck on whether you should bill codes with modifier -59, check the National Correct Coding Initiative (NCCI) edits, Parks says. If the codes you are reporting have indicators of "1" next to them, this means you can append the modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.

Time Saver: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary, experts say. Many private payers do not require a modifier for multiple-procedure scenarios or don't recognize -59 as a legitimate modifier. Check with your individual payer to see if modifier -59 is necessary when reporting multiple-procedure claims.

Tip: Each time you are unsure whether a carrier accepts modifier -59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification, Parks says. Then, chart each carrier's policies on -59 so you know whether to use it the next time you file a claim.

Making these phone calls may take a little time initially, but once you get a chart with each insurance company's policy on modifier -59, your claims department will be streamlined dramatically.

However, don't be afraid to use modifier -59 if you have to -- just make sure you've exhausted all other options and you are using it as it was intended, as the "modifier of last resort."

When your internist treats a patient who requires multiple procedures, you would include modifier -51 (Multiple procedures) on your claim.

Modifier -51 is "an informational-type modifier ... for use on the second, third, etc., surgical procedure performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

Example: Your ob-gyn performs a complete ultrasound on a 26-year-old patient in her 18th week of pregnancy. The doctor also performs a biophysical profile in the same session. You should:

Why? The modifier is appropriate because it shows that the two procedures are actually separate and that you're not "double-dipping" with your claim, Riesser says. In other words, modifier -51 indicates to the insurance company that the procedures were unrelated to each other.

On modifier -51 claims, the code that stands alone is the code that will be fully paid, so make sure you attach modifier -51 to the code with the lower RVU. "Modifier -51 prevents the insurance company from changing the order of your codes because the most expensive procedure should be listed first," Riesser says.

Payoff: The RVUs for 76805 are 3.61 for non-facilities, while 76818's RVUs are 3.20 for nonfacilities.

Remember: While reimbursement rates for codes with modifier -59 attached vary by payer, expect half the normal reimbursement for codes with modifier -51 attached. (Most insurance companies have adopted Medicare's policy paying 50 percent for codes with modifier -51 attached.)