Otolaryngology Coding Alert

Question: Should I use modifier 51 when billing multiple procedures?

New Hampshire Subscriber

Answer: Many payers, including several Medicare Administrative Contractors (MACs), recommend that you don’t use modifier 51 (Multiple procedures) on multiple procedures, even when appropriate, as it will be added to the proper codes by their claims software. This prevents the submission of claims with -51 appended to the wrong procedure code.

Medicare frequently rejects modifier 51, notes Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC, a Part A/B Medicare Administrative Contractor (MAC) in Nashville, Tennessee. “This is a system-generated modifier used to help payers appropriately price multiple surgical procedures performed on the same date of service. If you bill multiple surgical procedures on the same date of service, our system has to determine how to price all of those procedures, so it ranks them by the fee schedule amount, so the service allowed at the highest amount is allowed at 100 percent, but the second through fifth procedures performed on the same date are reduced down to 50 percent. If the services that you bill apply to multiple procedure pricing, our system will add that modifier, so please do not add this modifier because it could cause reimbursement problems for your procedures. The system handles how to rank or price these multiple procedures. If you add it to a procedure, our system may reduce that by an additional 50 percent, so that will cause some problems for you when it comes to reimbursement,” according to Lumpkin.

Tip: While this may be true for some payers, it is not a universal process, so your best bet is to check with each of your payers.

Note: Some coding experts prefer practices add modifier 51 unless the payer specifically instructs them not to because payers have been known to apply it to the higher/highest paying code and erroneously take the 50 percent reduction from that service.