Orthopedic Coding Alert

Modifiers -59 (Distinct procedural service) and -51 (Multiple procedures) have similar applications: to show the insurer that you performed medically necessary services that aren't usually billed together. The problem is that many coders and carriers have trouble choosing which modifier is appropriate for certain services. Knowing that modifier -59 is most often used to report services not normally billed together can help you determine when it should be assigned.

Modifier -59:The Unbundler?

According to CPT, modifier -59 is used in any of five situations: different sessions or encounters, different sites or organ systems, separate incisions/excisions, separate lesions, or separate injuries (or areas of injury). Tammy Boyer, CPC, coding and compliance administrator at Orthopedics and Sports Medicine, an orthopedic practice in Burlington, Iowa, refers to her CCI listing to determine whether modifier -59 should be added to a procedure code. "If the procedures I want to code together are considered bundled, and the code I want to use has a '1' by it, I use modifier -59 with the code, as long as one of the five situations [listed above] is taking place."

For instance, Boyer says, modifier -59 is appropriate when a patient undergoes a medial meniscectomy (29881) and lateral femoral condyle chondroplasty (29877). "The chondroplasty is considered bundled into the meniscecto-my, but because it was done in a different compartment, I append modifier -59 to it, and the claim gets paid."

Note: Always attach the modifier to the "column 2" or component (secondary) code, not the "column 1" or primary procedure code. Note that only CCI edits with a status indicator of "1" may be unbundled using modifier -59. Those code combinations with a status indicator of "0" may not be unbundled under any circumstances. You do not need to append modifier -59 if CCI does not bundle the multiple procedure codes you are billing for the same patient on the same day.

Modifier -59 should not lead to a reduction in reimbursement. Do not reduce your fees when billing, and appeal if the payer reduces your modifier -59 claims.

Keep in mind that modifier -59 should not be used indiscriminately to increase payments or protest CCI coding edits. Because of its ability to unbundle CCI edits and increase payments, payers may give modifier -59 special scrutiny. Therefore, always keep thorough notes available to substantiate its use. According to the July 1999 CPT Assistant, " CPT guidelines clearly indicate that the -59 modifier is only used if no more descriptive modifier is available and the use of the modifier -59 best explains the circumstances."

Modifier -51 Will Cut Your Fee

CPT states, "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) or service(s) may be identified by appending the '-51' modifier to the additional procedure or service code(s)."

For instance, if an orthopedic surgeon performs an arthroscopic anterior cruciate ligament repair (29888) and a meniscectomy (29881) on the same date, submit the claim with modifier -51 appended to 29881.

Procedures with modifier -51 appended to them are never paid at 100 percent. Instead, the payer reasons that many of the "component services" that make up the physician's total effort, such as preoperative and postoperative care, are already paid as part of the primary procedure and need not be separately reimbursed for the second and subsequent services. Since Jan. 1, 1995, payment for the second through fifth procedures has been fixed at 50 percent of the total allowable relative value units (RVUs), with the primary procedure paid in full.

Because modifier -51 results in an automatic fee reduction, always choose the highest-valued code as the primary procedure and attach modifier -51 to the lesser-valued procedure(s). Some payers, including many Medicare carriers, use software that automatically detects second and subsequent procedures and reimburses them accordingly, thereby making modifier -51 unnecessary. As always, request the payer's instructions in writing.

Assuming the payer requires modifier -51 for multiple procedures, you must consider still other factors before applying it. For example, modifier -51 should not be appended to any codes designated "modifier -51 exempt" because the RVUs assigned to them already account for their status as "additional" procedures.

When submitting a claim with modifier -51, do not reduce your fees for the second and subsequent procedures. The payer will base reimbursement on the fees you have listed. If you charge less than the full fee, your payment will still be reduced by 50 percent.