Modifier -51 Improves Payment For Multiple Ob/Gyn Procedures
Published on Sat Apr 01, 2000
Reimbursement for multiple ob/gyn procedures consistently emerges as a headache for coders. How do you get the maximum fair reimbursement for the amount of work that was done? How many procedures from the same session can you submit for reimbursement? What are some of the common pitfalls to multiple-procedure coding?
Conventional wisdom dictates that the -51 modifier (multiple procedures) will play a role in any coding picture for multiple procedures in the same session. CPT 2000 defines modifier -51 as: Multiple Procedures: When multiple procedures, other than evaluation and management 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 modifier -51 to the additional procedure or service code(s) or by the use of the separate five-digit modifier 09951.
So, the rules state that the primary procedure should be coded with no modifier and -51 should be appended to the second or any additional procedures. But how do you determine which is the primary procedure?
Code the Highest-priced Procedure as Primary
Melanie Witt, RN, CPC, MA, former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG), says that a common mistake when coding for multiple procedures is not putting the codes in the correct order. This does not mean, however, that the codes should be submitted in the order that the procedures were performed.
An inexperienced coder might look at the op report, find the first procedure performed, and code that procedure first, says Witt. But they should always code the highest-priced procedure first. The key is in the value of the primary procedurein the formatting of the procedures on the claim form, she adds.
But what about when your physician sets out to do procedure X, which is a $600 procedure, then during the course of the procedure, determines that procedure Y, which is valued at $1,000, is required?
Witt says when it comes to coding for multiple procedures, Original intent does not matter. Put the $1,000 procedure first, then the $600 procedure, and so on. You want to get paid in full for the highest-priced item, knowing that you will get, at best, 50 percent for the other procedures.
Wont the insurer balk at the order in which the procedures are coded?
Formatting of codes always takes place after the surgery, says Witt, and a minor procedure can easily lead to the discovery of a major problem. You may run into a problem with the insurer if you did not have pre-authorization, but you should still code using the highest-to-lowest-price method. Irrespective of what [...]
