Ob-Gyn Coding Alert

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 you were authorized or intended to do, the highest-priced procedure is the primary procedure from a purely coding perspective.

The rationale behind coding the higher-priced procedure first can be referred to as the 50 percent rule. Typically, insurers will pay 100 percent of the allowable on the first procedure, be it surgical or otherwise, and 50 percent of each subsequent procedure. So naturally, it makes sense to obtain 100 percent reimbursement on your highest-priced item.

Thomas Kent, CMM, principal of Kent Medical Management, a medical consulting firm based in Dunkirk, Md., echoes Witts sentiments. You do not want to use modifier -51 on the first procedure as this can cause the reimbursement to be reduced by half, says Kent. Each surgical procedure fee, with some minor exceptions, is created by the Health Care Financing Administration (HCFA) with the assumption that the procedure will be performed by itself. As HCFA does not wish to pay for the same service multiple times, modifier -51 indicates multiple procedures performed through the same surgical incision. Medicare, as well as most commercial carriers, reduces each additional procedure to half the allowed amount.

Use Modifier -51 Only When You Must

The -51 modifier commonly is associated with surgical procedures, but surgery is not the only area where the modifier applies. The rule of thumb, says Witt, is to remember that modifier -51 always applies for multiple surgical procedures, but it is not limited to surgery. Modifier -51 would be used for services as well, says Witt, such as when more than one ultrasound is performed at the same session. For example, if a complete obstetrical ultrasound is performed (76805, echography, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation]) and a biophysical profile is performed at the same session (76818, fetal biophysical profile), then the -51 modifier would append to the lower-valued code, in this case 76818.

Although the -51 modifier applies to nonsurgical services, it should not be used with lab services. A test is a test, says Witt. It is a stand-alone service that does not need a modifier just because more than one test was performed.

It is also important to remember that the -51 modifier is required only for multiple procedures in the same session by the same provider. Even in the rare instance when a patient leaves and comes back to the office later in the same day, only those procedures or services provided during the same session require the modifier.

Another common misuse of modifier -51 comes when unlike procedures are performed together. Witt offers the example of an amniocentesis using ultrasound guidance. The amniocentesis is coded 59000 (amniocentesis, any method), but the ultrasound (76946, ultrasonic guidance for amniocentesis, radiological supervision and interpretation) would not need a modifier. This is a different type of procedure, says Witt, so the modifier is not necessary. But if you did two different ultrasounds (as in the example given, using 76805 and 76818), you would need -51.

Number of Procedures Allowable in One Session

Is there a limit to the number of multiple procedures insurance companies will accept before they raise an eyebrow or two? Witt says, By convention, most payers will not pay for more than four surgical procedures or services without a very good reason for doing so. Thats because of the 50 percent rule. In the insurers mind, even at 50 percent for the additional procedures, theyre still paying out a lot of money. Youve got to have a pretty good reason for itemizing procedures beyond four in one session. Ive even heard of instancesthough fortunately this is the exception to the rulewhere the insurer pays 100 percent on the first procedure and then 0 percent on the rest.

Kent maintains that the -51 modifier is designed for procedures that take place at the same operative site. HCFA does not wish to pay for the opening and closing of the same wound multiple times (meaning that each fee has that service built into it), says Kent. So modifier -51 indicates multiple procedures performed through the same surgical incision. Therefore, when it is necessary to perform an additional procedure from a different operative site or on a different part of the body, do not use the -51 modifier as you should be paid in full.

Witt contests this because many insurers contacted during informal ACOG polls regarding their accepted use of modifiers had indicated that they expected the modifier -51 to be used on any multiple procedure at the same surgical session. She indicates that although coders can try to code without the -51 modifier on additional surgical procedures performed through a different incision, Coders may find that the insurers claims-processing system simply reduces the allowable on the subsequent procedures anyway. In fact, some payers do not recognize modifiers at all, but still reduce the allowable for the second, third, etc., procedures.

But Kent and Witt both agree that the fee should never be reduced when using the -51 modifier. Kent explains: A significant number of commercial insurance plans figure the -51 modifier reduction based on the least of your submitted charges or their allowed amount.
Therefore, if you submit half your normal fee, and this is lower than the allowed amount, the insurance plan will pay half of your submitted fee.