Orthopedic Coding Alert

In CPT 2008, you won't find the familiar X symbol, signifying modifier 51 exemption, next to external fixation codes 20690 and 20692. In fact, CPT removed many codes from the modifier 51 exempt list. Here's what the change means for you.

The lowdown: Modifier 51 (Multiple procedures) underwent a major overhaul for 2008, with a new set of criteria for whether a code should be on the modifier 51 exemption list (CPT Appendix E), according to Claudia Bonnell, RN, MLS, project manager with Blue Cross Blue Shield Association in her "CPT Modifiers" presentation at the AMA's CPT and RBRVS 2008 Annual Symposium (http://www.ama-assn.org/ama1/pub/upload/mm/362/07pres-tab10.pdf) in November.

To stay on the list, a code must meet 1-5 and either 6 or 7 of the following, according to the AMA's CPT Changes 2008: An Insider's View:

1. Relative Value Scale Update Committee (RUC) rationale must support keeping the service on the list. For example, the code is priced based on modifier 51 exemption.

2. Listed procedures shouldn't be subject to Medicare multiple-procedure reduction.

3. An exempt service should have minimal pre- and postservice time relative to the intraservice time.

4. Listed services can't be add-on codes.

5. If logic says code A payment shouldn't be reduced when performed with another procedure, code A doesn't belong on the list.

6. Listed services should typically be performed with another procedure but may stand alone.

7. Listed services are performed with so many other procedures that printing a "report with" list in CPT would be difficult.

CPT 2008 removed 20690 (Application of a uniplane [pins or wires in one plane], unilateral, external fixation system) and 20692 (Application of a multiplane [pins or wires in more than one plane], unilateral, external fixation system [e.g., Ilizarov, Monticelli type]) from Appendix E because the codes don't meet numbers 2 (not subject to multiple-procedure reduction) and 3 (minimal pre- and postservice time), according to CPT Changes 2008.

Call it even: Although modifier 51 reduces your reimbursement, losing exemption for your external fixation (ex fix) codes shouldn't do too much damage to your pocketbook because of an RVU change. For example, in 2007, 20692 had 11.10 RVUs, but it has 23.84 in 2008.

Important: Many payers--- including most Medicare carriers--- don't want you to use modifier 51 anyway. The payer will automatically sort the procedures on your claim in order from highest to lowest RVUs. The payer will reimburse the highest-ranked procedure at 100 percent and any additional surgical procedures at 50 percent.