Medicare Compliance & Reimbursement

Navigate conflicting preferences with this expert advice.

Be cautious when using modifier 51 (Multiple procedures). While the Centers for Medicare & Medicaid Services (CMS) has excellent advice on how to use this modifier, other payers warn against using it on your Medicare claims.

To navigate the variations between Medicare’s advice and your MACs’ preferences, you’ll have to cross-reference your payer policies with Medicare’s regulations.

Use Modifier on ‘More Major’ Surgery

Although many practices haven’t brushed up on their modifier 51 skills in years, CMS believed the topic was ripe for an education session. “Modifier 51 is a modifier used to report multiple procedures — in other words, when a patient has had more than one surgery on the same day and Medicare allows for separate payment,” said CMS’s Angela James during her Feb. 24 “CMS Provider Minute,” which covered exactly when you should use the elusive modifier 51. “The rule is that the second and any other surgeries are subject to a 50 percent reduced reimbursement. To be paid properly, you have to carefully apply the rules for surgical modifiers.” Needless to say, this means you’ll list your ‘big ticket’ procedures first.

“The rule for billing multiple surgeries by the same physician on the same day goes like this,” James advised. “Report the more major surgical procedure without the multiple procedures modifier (modifier 51), and then report additional surgical procedures performed by the surgeon on the same day with modifier 51.”

MACs Often See Things Differently

Unfortunately, despite CMS’s clear vision for modifier 51, Medicare’s administrative contractors might have a different view on whether you should use it on your multiple procedures. For example, Part B payer Noridian Healthcare Solutions says, “Do not append modifier 51 to the additional procedure code. The Medicare claim processing system has a hard-coded logic to append it to the correct procedure code. CPT^® also lists codes that are modifier 51 exempt.”

Likewise, Part B MAC WPS Medicare says, “Medicare does not recommend reporting modifier 51 on your claim; the processing system has hard-coded logic to append the modifier to the correct procedure code.”

So what should you do? Contact your payers and ask whether they require the modifier. Typically, if they process claims electronically like MACs do, they won’t need the modifier.