Neurosurgery Coding Alert

Here's what -modifier 51 exempt- really means for your bottom line

Anytime you report an -add-on- procedure code, you must also be sure to report an approved, primary procedure code on the same claim. To better illustrate the consequences of add-on status, we-ll use the example of spinal bone graft codes--and add-on codes--20930-20938.

Add-On Can't Stand Alone

You should never report an add-on code alone. By definition, an add-on code describes an -additional- service that occurs only at the same time as another, more extensive procedure, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center. Generally, CPT will include an editorial note, following the add-on code's descriptor, to instruct you as to which primary procedure codes should precede that add-on code.

Example: For all spinal bone graft procedures 20930-20938, the appropriate, approved primary procedures are 22319 (fracture treatment) and 22532-22533, 22548-22558, 22590-22612, 22630 and 22800-22812 (arthrodesis/spinal fusion). You can find these instructions immediately following each of the code descriptors for 20930-20938.

You may occasionally report more than one type of add-on code during the same operative session.

For instance, in addition to arthrodesis, spinal bone grafts also frequently occur during the same session as spinal instrumentation procedures (22840-22855). The spinal instrumentation procedures are themselves represented with add-on codes, and you may report them in addition to any spinal bone grafts and arthrodesis.

CPT supports this coding with instructions preceding both the arthrodesis and spinal instrumentation codes advising, -To report bone graft procedures, see 20930-20938. (Report in addition to code[s] for definitive procedure[s].)- And although the national Correct Coding Initiative (CCI) bundles various bone grafts into many orthopedic procedures, such bundles do not apply to spinal bone grafts with arthrodesis (22548-22812) and/or spinal instrumentation (22840-22855) procedures.

Avoid Modifier 51, or Pay the Price

You should never append modifier 51 (Multiple procedures) to a designated add-on code.

Modifier 51 designates a procedure or service that is usually performed independently but, in the cited case, is performed at the same time as another procedure. Because add-on codes are already defined as additional services or procedures, modifier 51 is redundant and, for some payers, can even harm your reimbursement, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, manager of compliance education at the University of Washington Physicians.

CPT stresses this point by stating, -All add-on codes found in the CPT book are exempt from the multiple procedure concept.- That is, the payment value assigned to these codes reflects their status as -additional procedures,- and therefore any further reduction in reimbursement is unwarranted and unjustified.

CPT 2008 Changes: An Insider's View goes even further, stating, -As modifier 51 exempt codes are typically adjunctive or reported with other procedures, the amount of pre- and post-service time associated with these codes is minimal and use of modifier 51 to signify further reduction would be inappropriate.- And, -Both add-on and modifier 51 exempt codes are similar in that neither should be subject to multiple procedure reductions-

Returning to the example of spinal bone grafts, going as far back as February 1996, CPT Assistant stated, -Codes 20930-20938, although appearing under the heading of General Musculoskeletal Procedures, apply only to bone grafts used for spine surgery ... These are specifically identified as add-on procedures. The 51 modifier is not used when these codes are reported with the definitive spine surgery code.-

Keep an Eye on the Bottom Line

Always check your explanation of benefits carefully for claims with add-on codes to be sure the payer is reimbursing you the entire fee schedule rate for the billed procedures or services.

Often, when a physician performs multiple procedures, the payer will reduce payment for the second and subsequent procedures because the pre-surgery evaluation, preparation and postsurgical care are already covered under the cost of the first procedure, Bucknam says. As explained above, however, this logic does not apply to add-on procedures.

Fight reductions: If you find a payer reducing the fees for your add-on codes (not just for spinal bone grafts, but for any add-on procedure), be sure to appeal the claims. Cite AMA guidelines from the -Introduction- of the CPT Manual, which clearly state, -All add-on codes found in the CPT book are exempt from the multiple procedure concept.-

Look for -+- to Identify Add-Ons

Although the -add-on- designation in CPT applies to many procedures and services, from E/M to surgical procedures to use of equipment, all add-on codes share the following characteristics:

- They are denoted in the CPT book with a -+- to the left of the code
- The CPT code descriptor will include some version of the phrase -list separately in addition to code for primary procedure-
- They should always be used with a -primary- procedure (parent) code(s)
- They should never be listed as a primary procedure
- They should never be listed with modifier 51 appended
- Payment for these services should not be lowered by the multiple-surgery reduction.