Neurology & Pain Management Coding Alert

Physicians, coders and payers alike often have trouble distinguishing between modifiers -59 (Distinct procedural service) and -51 (Multiple procedures) because they have similar applications. But a quick review of coding guidelines and as a last resort, a well-placed call to the insurer can help you choose between the modifiers with confidence.

Use -59 to Unbundle

CPT specifies that you should use modifier -59 to indicate a procedure or service that is distinct or independent from other services performed on the same day and, further, that the two services/procedures are not normally reported together, but are appropriate under the circumstances. Specifically, CPT allows you to apply modifier -59 in five situations:
 
 1. Procedures performed at different sessions or encounters
 2. Procedures performed at different sites or organ systems
 3. Procedures performed at separate incisions/excisions
 4. Procedures performed at separate lesions
 5. Procedures performed at separate injuries.

Two procedures may correspond to different diagnoses, but not necessarily so, and modifier -59 never applies to E/M services. General coding principles dictate that you may report only one E/M service per day and that modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), rather than modifier -59, applies when reporting an E/M service and another, non-E/M service on the same day.
 
In a neurology practice, modifier -59 is most useful in unbundling edits set forth by the National Correct Coding Initiative (NCCI). For instance, NCCI bundles 95900 (Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) to 95903 (... motor, with F-wave study). If the physician performs a nerve conduction study (NCS) without F-waves at the same time but on a different nerve (for example, ulnar versus median) as an NCS with F-waves (for instance, during diagnostic testing for carpal tunnel syndrome), you may bill 95900 in addition to 95903 if you append modifier -59 to the former (that is, the component code) to indicate a separate anatomic location. In this case, the insurer should reimburse 95900 and 95903 separately.
 
As a second example, biofeedback (90911) involves electromyography (EMG) procedures 95860-95872 to detect and record muscle activity. Therefore, if the physician administers an additional EMG as a separate medically necessary service for the diagnosis or follow-up of organic muscle dysfunction, bill the appropriate EMG code(s) with modifier -59 appended to indicate a separately identifiable diagnostic service with 90911.
 
Note: Always attach the modifier to the column 2 or component (secondary) code, not the column 1 or primary procedure code. You may report only NCCI edits with a 1 status indicator using modifier -59. You may not unbundle code combinations with a status indicator of 0 under any circumstances.

Watch Your -59 Payments

Generally, modifier -59 should not lead to a reduction in reimbursement but keep in mind that you should not use modifier -59 indiscriminately to increase payments or protest NCCI coding edits. Because of its ability to override NCCI edits and increase expenditures, payers give modifier -59 claims special scrutiny. Therefore, always keep thorough notes available, outlining the separate and distinct nature of the billed procedures, to substantiate its use.
 
Occasionally, reimbursement with modifier -59 is carrier- or situation-driven. Be sure to ask for the payers modifier -59 policy in writing so you can anticipate these circumstances and protest any reduction not specified in the payers guidelines.
 
Remember that modifier -59 is the modifier of last resort, as Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb., describes it. According to the July 1999 CPT Assistant, CPT guidelines clearly indicate that the -59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances.

Always Attach -51 to Lesser Procedure

CPT Appendix A states, When multiple procedures, other than E/M services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the -51 modifier to the additional procedure or service code(s).
 
Multiple procedures are distinguished from procedures that are components of or incidental to the primary procedure (for instance, services bundled by the NCCI and to which you append modifier -59 for the purpose of separate identification).
 
For example, when required by the payer (see below), use modifier -51 to report multiple injections of a neurolytic substance or translaminar epidural. When billing for these services, code each injection separately with modifier -51 appended to the second and subsequent codes. If the surgeon provides two epidural injections of a neurolytic substance one each at a cervical and lumbar level you should report the service as 62281* (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, cervical or thoracic) and 62282*-51 (... epidural, lumbar, sacral [caudal]). Documentation must support each code independently, outlining the dosage, location and medical necessity for each injection.
 
Payers rarely reimburse multiple-procedure claims at 100 percent. Instead, they reason that many of the component services that make up the physicians total effort when performing a particular service, such as any inherent pre- or postoperative E/M, are already paid as part of the primary procedure and need not be separately reimbursed for the second and subsequent services. Since Jan. 1, 1995, Medicare payment for the second through fifth procedures has been fixed at 50 percent of the total allowable relative value units (RVUs) for the particular CPT code, with the primary procedure paid in full. Many private payers also follow this convention.
 
Because modifier -51 results in an automatic fee reduction, physicians must use it with care or risk losing reimbursement to which they are entitled.
 
Always choose the highest-valued code as the primary procedure and attach modifier -51 to the lesser-valued procedure(s), says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. In the above example, for instance, choose 62281 as the primary procedure because it has been assigned more RVUs than 62282 (3.44 versus 3.09 RVUs, respectively).

Payer Determines Whether -51 Is Necessary

Before deciding whether modifier -51 is appropriate for a given claim, contact the payer. Modifier -51 is really going out of style and simply isnt necessary in many cases, Bucknam says. Many payers, including most Medicare carriers, use software that automatically detects second and subsequent procedures and reimburses them accordingly, thereby making modifier -51 unnecessary. As always, request the payers instructions in writing. Documentation is your best defense if the payer questions your billing methods. Although contacting the payer may require a little time initially, it will help you to be more efficient in the long term.
 
Assuming the payer does require modifier -51 for multiple procedures, the coder must consider still other factors before applying it. For example, modifier -51 should not be appended to any codes denoted by CPT with a + (these codes are listed in appendix E of CPT). Such codes (which include, for instance, nerve conduction studies 95900-95904) are designated modifier -51 exempt because the RVUs assigned to them already take into account their status as additional procedures. If you append modifier -51 to an add-on code for which the fee is already reduced, a further and inappropriate 50 percent reduction may occur.