Podiatry Coding & Billing Alert

Question: I am new to coding, and I’m trying to understand the Resource-Based Relative Value Scale (RBRVS) in relation to modifiers. When using the RBRVS are there relative value units (RVUs) for modifiers 25, 26, 51, 52, 57, 59, and 80?

California Subscriber

Answer: The official RBRVS does not assign RVUs to any modified code — except for modifier 26 (Professional component) and modifier TC (Technical component). RVUs simply represent the procedure’s value.

When you calculate your location’s allowable, then you can calculate the Medicare reduction for modifier 80 (Assistant surgeon) or modifier 51 (Multiple procedures). Under Medicare rules, a surgical assistant is paid 16 percent of the allowable, while the normal multiple procedure reduction is 50 percent of the allowable for the second through fifth additional procedure. Your payer may or may not reimburse a sixth additional procedure.

Modifier 59 (Distinct procedural service) has the same reduction as modifier 51. Why: When you apply modifier 59, you usually are applying it to secondary bundled procedures. In other words, the modifier 59 tells the payer that the payer should not deny the procedure but treat it as any other multiple procedure.

You won’t have any reduction for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) or modifier 57 (Decision for surgery). Why: The payer will decide to either pay the E/M service or deny it.

Also, you cannot calculate the reduction for modifier 52 (Reduced services).  Why: The payer will decide your reimbursement based on your podiatrist’s description of the work she did not perform.