Orthopedic Coding Alert

Modifier -51 (multiple procedures) has been used widely in orthopedic settings, where surgeries of the hand, knee, foot or shoulder can often result in numerous procedures being done at the same time. Although there is still some confusion concerning the use of modifier -51, increasingly, orthopedic coders report that carriers including Medicare no longer require it.

When to Use Modifier -51

Modifier -51 typically has been used when the same physician performs multiple procedures in the same session. CPT 2000 describes use of -51 as follows:

When multiple procedures, other than E/M 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) may be identified by appending the modifier -51 to the additional procedure or service code(s) or by use of the separate five-digit modifier 09951.

The July 1999 CPT Assistant further clarifies the proper use of modifier -51:

It does not apply to evaluation and management (E/M) codes, designated add-on codes, or codes designated as modifier -51 exempt. The use of the -51 modifier is not restricted to operative procedures, although it is commonly used in this context.

Section 4826 Claims for Multiple Surgeries in the Medicare Carriers Manual Part 3 provides further rules for billing with modifier -51:

B. Billing Instructions. Instruct billers to use the following guidelines when billing for multiple surgeries by the same physician on the same day.

Report the more major surgical procedure without the multiple procedures modifier - 51.
Report additional surgical procedures performed by the surgeon on the same day with modifier -51.

Medicares reimbursement rate for multiple procedures has become the industry standard for claims payment, with most commercial carriers adopting a similar payment policy. It allows for base payment for each ranked procedure on the lower of the billed amount or 100 percent of the scheduled fee amount for the highest valued procedure and 50 percent of the scheduled fee amount for the second through fifth highest valued procedures.

Where to Use Modifier -51

Kerstin Conner, billing specialist at Orthopedic Foot and Ankle Center, a two-surgeon practice in Columbus, Ohio, expresses some confusion over the proper use of modifier -51. We are told to use it different ways, says Conner, such as only when there is more than one surgery code billed or only when there are multiple surgeries done in the same area or the same incision.

She says that they typically append modifier -51 when billing for 27640 (partial excision [craterization, saucerization, or diaphysectomy] bone [e.g., osteomyelitis or exostosis]; tibia) when done in conjunction with 29898 (arthroscopy, ankle [tibiotalar and fibulotalar joints], surgical; debridement, extensive) and 28120 (partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; talus or calcaneus). So the coding sequence submitted would read as follows: 27640, 29898-51, 28120-51.

Modifier -51 was intended for coding all procedures beyond the major one. For that reason, the golden rule of coding multiple procedures is to identify the major procedure and record that code on the first line. The major procedure is also the most expensive onethe one for which the coder expects full allowance and reimbursement. Carriers will reduce fees for all subsequent procedures. By appending modifier -51 to secondary procedures, the coder is telling the carrier which procedures to reduce. But in spite of walking the adjuster through the claim form, Billie Jo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopaedic and Sports Medicine in Cincinnati, Ohio, a six-office practice with 18 physicians, points out that practices should always charge in full for multiple services. We used to reduce the fees for multiple procedures, says McCrary. But as our reimbursements became more difficult to obtain over the years, we no longer do that. Her rationale is to leave it to the carrier to reduce the pay back, dont make it easier for them to do so by reducing your fees at the outset.

Karen J. Faler, RN, C-ONC, president of the National Association of Orthopedic Nurses and orthopedic care coordinator at Provena Covenant Medical Center in Illinois clarifies some of Conners questions as to the rules for using -51. The multiple procedure implied by -51 need not be at the same incision site, says Faler, but it does have to be during the same surgical event. Faler points out that especially in orthopedic surgeries, multiple procedures are the norm. Especially when you are treating a trauma patient, she says, you will perform many procedures in the same setting, even in the same incision. She cites arthroscopic procedures where as many as four different procedures may be done at one time. Occasionally, practices may get a request for further clarification of a multiple claim from the carrier. Then its just a matter of pulling the operative notes and explaining that the procedures are all related to one another.
Usually, says Faler, these requests come with surgeries on things like knee joints, where you have to repair both structural and mechanical aspects and work with both soft tissue and bony material.

Is Modifier -51 No Longer the Way to Go?

A growing number of coders in all medical specialties report that modifier -51 is not being used by carriers nearly as frequently as it used to be. Joan Shurbet, RN, ONC, manager of the surgical division at the Christie Clinic, a multispecialty clinic in Champagne, Ill., points out that the -51 modifier is required less frequently, as more descriptive codes for orthopedic procedures are released. I rely heavily on the Academys (AAOS) manual, Global Service Data for Orthopaedic Surgery, as to what they consider part of the global surgery.

McCrary says that the local Part B carrier in Ohio no longer accepts the modifier. Multiple procedures are reimbursed based on the relative value assigned to each code. Therefore, the -51 modifier is no longer necessary for Medicare. Yet a commercial carrier with whom McCrary works frequently insists on the -51 to the point of appending it to codes if McCrary doesnt do it first. They put the -51 on codes whether we do or not, says McCrary, and sometimes inappropriately so. Modifier -51 was created to show carriers that extra work was being done, not as a means for carriers to reduce payment.

McCrary says that, increasingly, coders are turning to modifier -59 (distinct procedural service) as a means to ensure proper reimbursement. She cites 29877 (arthroscopy, knee, surgical; debridement /shaving of articular cartilage [chondroplasty]) as an example. A few years ago, if performing the chondroplasty in more than one compartment, we would have listed this code twice with a -51 modifier. But now, carriers are often throwing out the second procedure, saying we are submitting duplicate claims. The -59 modifier tells the payer that a second chondroplasty was performed on a second compartment of the knee, thus its appearance twice on the same claim form. Even so, she finds appeals are more prevalent than they used to be. The carriers, including Medicare, says McCrary, have a list of acceptable modifiers, but using them seldom affects reimbursement. They pay what they want to pay anyway.

Editors note: Use caution when appending modifier -59. This modifier allows coders to override computer bundling edits. While doing so may result in reimbursement, it also may cause problems when an audit reveals that your practice was reimbursed improperly for legitimately bundled edits. Be sure to refer to the AAOS Global Service Data for Orthopaedic Surgery to determine which codes are bundled with others before appending -59.

Another modifier option for multiple procedures are the HCPCS modifiers to indicate left and right sides of the body (-LT and -RT), and fingers (-F1, -F2, etc.) and toes (-T6, -T7, etc.). Even with codes that specify each, indicating that they are separate procedures (e.g., 28525, open treatment of fracture, phalanx or phalanges, other than great toe, with or without internal fixation, each), McCrary still uses the HCPCS modifiers. In addition to appending the HCPCS modifiers for the different toes, she says, I actually write, first toe, second toe, third toe on the claim form the first time around because I know if I dont, they will deny it as duplicate.

Ultimately, it appears as though it is up to the individual carrier to decide which modifiers are preferable for multiple procedures. That may mean using -51, -59 and the HCPCS modifiers, depending on the carrier to which billing is being submitted. By identifying the carriers policy in writing, being explicit about what procedures were performed, and citing the carriers own rules for multiple procedures, coders have the best case for fair reimbursement.