Neurology & Pain Management Coding Alert

Proper application of -25, -51 and -59 means success for multiple procedures

If you're reporting two or more CPT codes for the same patient on the same day, chances are you'll need a modifier. Depending on whether one of the codes represents an E/M service or whether the procedures you wish to claim are bundled by NCCI, your choices boil down to -25, -51 and -59.

Pair -25 With E/M Service

If the neurologist performs a legitimate E/M service and another service or procedure for the same patient on the same date of service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code.

How to use -25: A patient with carpal tunnel-like symptoms arrives for an initial consultation with the neurologist. The neurologist takes a full history, examines the patient and conducts electromyography and nerve conduction studies.

In this case, you should report the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas, and 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), along with 99243 (Office consultation for a new or established patient ...) for the E/M service. Because you are billing the test codes and the E/M service on the same date, you should append modifier -25 to 99243.

"CMS guidelines stipulate that all procedures include an 'inherent' E/M component," says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a premier medical billing company in Brick, N.J.

Therefore, to differentiate the inherent E/M component of an EMG, for instance, from a truly significant and separately identifiable E/M service, you should append modifier -25. "This tells the payer that the E/M service the physician provided was above and beyond that needed simply to carry out the other services claimed," Cobuzzi says.

Separate documentation helps: To further differentiate your same-day E/M claims, you should document the E/M service on a separate sheet from the other procedures the neurologist performs on the same date.

For instance, the physician could document the history, exam and medical decision-making in the patient's chart, and record the procedure notes on a different sheet attached to the chart, says Brenda W. Messick, CPC, a coding specialist in Atlanta.

Remember, date of service matters: Suppose a patient presents early in the day for an injection (for example, 20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]) for neck pain (723.1). Later in the day, the patient begins to feel dizzy and nauseated. Fearing an adverse reaction to the injection, the patient returns to the neurologist's office. The neurologist evaluates the patient and documents a level-three E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

In this case, you must still append modifier -25 to 99213. Although the injection and E/M service occurred at separate patient encounters, they still occurred on the same date of service.

Choose -51 for 'Additional' Services

For multiple, for non-E/M services on the same date of service, you will sometimes need to choose modifier -51 (Multiple procedures).

Modifier -51 is "an informational-type modifier for use on the second, third and other subsequent procedures the physician performs on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

Payers reason that many of the "component services" that make up the physician's total effort when performing a particular service (such as preservice evaluation and postservice care) are already paid as part of the initial or primary procedure.

In other words, the multiple-procedure reduction is the payers' way of avoiding redundant charges for shared work under two or more codes.

Typically, payers will reimburse 100 percent of the assigned relative value units (RVUs) for the primary (highest-valued) procedure and 50 percent of the assigned RVU value for subsequent procedures (that is, any procedures with modifier -51 appended).

Before using -51, you should check three things:

1. Your payer still requires modifier -51: Many payers no longer require that you use modifier -51 because they have adopted computerized billing programs that automatically sequence codes according to their RVUs. For these payers, you should skip using modifier -51 for your claims.

2. The codes you are billing are not modifier -51 exempt: Many codes in CPT, including all "add-on" codes (designated with a "+" next to the code) and any code specifically noted as modifier -51 exempt (look for the "circle with a slash" next to the code), do not require that you append modifier -51. You can find a complete list of modifier -51 exempt codes in Appendix E of CPT. 

3. NCCI does not bundle the codes: If the National Correct Coding Initiative bundles the codes you wish to bill together, modifier -51 won't override the edit.

How to use -51: The neurologist provides one epidural injection of a neurolytic substance at cervical and lumbar levels. In this case, the payer does require modifier -51. You should report 62282 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, lumbar, sacral [caudal]) and 62281-51 (... epidural, cervical or thoracic).

You should append modifier -51 to 62281 because it is the lesser-valued procedure. The payer should reimburse 62282 at full value and pay for 62281 at 50 percent of the usual rate.

Distinct Services Warrant -59

The key when reporting modifier -59 (Distinct procedural service) is having documentation to prove that the second service is distinct from the initial procedure. This includes 1) an explicit diagnosis supporting the medical necessity of the additional service, and/or 2) documentation proving that the additional procedure occurred at a distinct anatomic location, says consultant Annette Grady, CPC, CPC-H, with Eide Bailly in Bismarck, N.D.

Although modifier -59 is similar to modifier -51, it serves a different function in that you may use -59 to override NCCI edits. Payers pay close attention to -59 claims. You must apply -59 with caution and not as an indiscriminant method to get claims paid, Grady says.

How to use -59: During the same session, the neurologist performs a nerve conduction study (NCS) without F-wave (95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and an NCS with F-wave (95903, ... motor, with F-wave study) on a different nerve. Typically, NCCI bundles 95900 to 95903 and will not pay separately for the studies.

In this case, however, because the tests occurred on different nerves, the neurologist can rightly claim payment for both procedures. Therefore, to indicate that the tests occurred at distinct anatomic locations and to override the NCCI edit, you should report 95903 and also append -59 to 95900.

Don't sit still for denials: Dealing with carrier rejections can be one of the biggest challenges when reporting modifier -59. If your insurer denies your modifier -59 claim, you may want to appeal the denial and send a copy of your operative note with your appeal. As long as you maintain the necessary documentation to support your claim, you can confidently append modifier -59 to your claims and expect appropriate reimbursement.