Internal Medicine Coding Alert

Question: I noticed that CPT includes modifier -51 for "multiple procedures." I never append this modifier when reporting multiple procedures and have never had difficulties with the payer. Am I facing a possible audit?

Pennsylvania Subscriber

Answer: Your payer probably doesn't require modifier -51 (Multiple procedures), which means you are in no danger of an audit for failing to append the modifier to multiple-procedure claims. Many payers, including the majority of Medicare carriers, 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: Documentation is your best defense if your billing methods are questioned.
 
If your payer does require modifier -51, you must consider several factors before appending it. For example, you should not use modifier -51 with any codes notated in CPT with the symbol O with an over it (these codes are also listed in appendix E of CPT). Such codes are "modifier -51 exempt" because the relative value units assigned to them already take into account their status as "additional" procedures. And you should not append modifier -51 to E/M codes. Also, because payers reduce fees for "subsequent" procedures, you should always choose the highest-valued code as the primary procedure and attach modifier -51 to the lesser-valued procedure(s).

 - Answers for You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.