Ophthalmology and Optometry Coding Alert

Question: I previously often used modifier 51. Now, I'm unsure when it is required. Do some carriers no longer accept it?

Kansas Subscriber

Answer: Appending modifier 51 (Multiple procedures) on certain claims may not be necessary for all insurers. Many carriers no longer require modifier 51.

Processing claims electronically allows the carrier to recognize when your physician performs multiple procedures and automatically make the necessary reduction in payment. Remember to always list the highest-paying procedure code first.

Tip: Make a pre-emptive strike against denials by contacting your insurance carrier and asking the representative which method the insurer would prefer when reporting multiple surgical procedures. Note each payer's policy on coding multiple procedures so you can reference it quickly the next time a modifier 51 issue arises.

Rule of thumb: Modifier 51 is an informational-type modifier for use on the second, third, etc., surgical procedure performed on the same day as another procedure that you are reporting and seeking payment for.

Example: The ophthalmologist excises two lesions (2 cm and 0.5 cm) from a patient's eyelids. Use 11442 (Excision, other benign lesion including margins [unless listed elsewhere], face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) and 11440-51 (... excised diameter 0.5 cm or less; multiple procedures).

Note that you may also need to append an eyelid modifier (E1 for upper left, E2 for lower left, E3 for upper right, and E4 for lower right) to indicate where the lesions were.

The modifier shows the carrier that the physician performed both procedures in the same session. Append modifier 51 to 11440 because it is the lesser-valued procedure. The payer should reimburse 11442 at full value and pay for 11440 at a reduced rate (usually 50 percent of the standard fee). Also, check Appendix E of the CPT manual for a list of codes that are 51-modifier exempt.