Neurosurgery Coding Alert

Physicians, coders and carriers 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.

According to CPT, you may append modifier -59 in any of five situations: procedures performed at different sessions or encounters, different sites or organ systems, separate incisions/excisions, separate lesions, or separate injuries (or areas of injury). Note that "separate" can indicate an independent diagnosis linked to the procedure to which you have appended modifier -59, but not necessarily so.

Tammy Boyer, CPC, coding and compliance administrator at a Burlington, Iowa, surgical practice, refers to her national Correct Coding Initiative (CCI) listing to determine whether modifier -59 should be added to a procedure code. "If the procedures I want to report together are bundled and the code I want to use has a '1' next to it in CCI, I use modifier -59 with the code, as long as the situation meets one of the five CPT requirements [listed above]."

For instance, the surgeon performs a lumbar decompression followed by a lumbar microdiskectomy at a different level. Each procedure is associated with a different diagnosis. The coder may report 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar) and 63030 (Laminectomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) at the same time. CCI bundles these procedures, but the edit includes a "1" indicator. Therefore, you may append modifier -59 to the microdiskectomy "to differentiate between the services provided" at different times or (as in this case) at different locations on the body. But if the surgeon extends the laminectomy to remove a disk at the adjacent level, you may not append modifier -59 because the procedure is not occurring at a separate anatomical area.

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" CCI coding edits. Because of its ability to unbundle CCI edits and increase payments, payers may give modifier -59 special scrutiny. Therefore, always keep thorough notes available to substantiate its use.

Finally, 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 CPTAssistant, "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."

Appendix Aof CPTstates, "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 example, services bundled by the CCI and to which you append modifier -59 for the purpose of separate identification). For example, when required by the payer (see below), you can 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. For instance, if the surgeon provides two epidural injections of a neurolytic substance one each at a cervical and lumbar level the service should be reported 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 supporteach code independently, outlining the dosage, location and medical necessity for each injection.

Payers rarely reimburse multiple-procedure claims at 100 percent. Instead, payers reason that many of the "component services" that make up the physician's 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 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 relative value units (RVUs) than 62282 (3.44 versus 3.09 RVUs, respectively).

Before deciding if modifier -51 is appropriate for a given claim, contact the payer. "Modifier -51 is really going out of style and simply isn't necessary in many cases," Bucknam notes. 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 payer's 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 coders 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 "+" or "O" (these codes are listed in appendix E of CPT). Such codes 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.                                              

Right or Wrong,Insurer Has Last Word

Occasionally a payer will specify that you use modifier -59 where -51 or no modifier at all may seem to be more appropriate. For example, some payers will ask that you append modifier -59 when reporting multiple units of +63048 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis], single vertebral segment; each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]). Neither CPT nor CCI would make this step necessary (the code descriptor clearly specifies "each additional segment," and CCI does not bundle the code to itself), but failure to append modifier -59 for certain payers may nonetheless result in non-payment.

When in doubt about an insurer's policy, ask for instructions in writing and follow them to the letter.