Neurology & Pain Management Coding Alert

Question: CPT includes a modifier (-51) for "multiple procedures." I never append this modifier when reporting multiple codes (such as same-day nerve conduction studies and electromyography) and have never had difficulties with the payer. Am I facing a possible audit?

Pennsylvania Subscriber

Answer: More than likely, your payer doesn't require modifier -51 (Multiple procedures), and you are in no danger of an audit because you have failed to append it to multiple code 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 as modifier -51 exempt (these codes are listed in appendix "E" of CPT). Such codes are exempt because the relative value units assigned to them already account for their status as "additional" procedures.
 
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). For example, if you report multiple injections of a neurolytic substance or translaminar epidural, code each injection separately with modifier -51 appended to the second and subsequent (lesser-valued) codes.
 
For instance, if the neurologist provides two epidural injections of a neurolytic substance - one each at a cervical and lumbar level - you should report the service 62282 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; epidural, lumbar, sacral [caudal]), 62281-51 (... epidural, cervical or thoracic). Documentation must support each code independently, outlining the dose, location and medical necessity for each injection.
 
In this case, 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 a reduced rate (usually 50 percent of the standard fee).