Ophthalmology and Optometry Coding Alert

Question: I notice CPT includes a modifier (-51) for "multiple procedures." I never append this modifier when reporting multiple codes (such as eyelid lesion removals) and have never had difficulties with the payer. Am I facing a possible audit?

Pennsylvania Subscriber

Answer: Many payers use software that automatically detects secondary procedures and reimburses them accordingly, thereby making modifier -51 (Multiple procedures) unnecessary. But be careful when billing Medicare or other federally funded insurance plans. If you do not append modifier -51 and the carrier overpays you by mistake, it will be the result of sending an incorrect claim, which could land you in hot water. You should check with your individual payer for its guidelines and, as always, request the payer's instructions in writing.

Watch out: Do not use modifier -51 with any codes notated in CPT with a  backwards  or "+" (these codes are also listed in appendixes "D" and "E" of CPT). Such codes are "modifier -51 exempt" because the relative value units assigned to them already take into account their status as "additional" procedures.

Also, because payers reduce fees for "subsequent" procedures, you should always choose the highest-valued code as the primary procedure and attach modifier -51 to the lesser-valued procedure(s).

Example: The ophthalmologist excises two lesions (2 cm and 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.

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).

- Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, president of Practice Solutions, Santa Barbara, Calif.