Pulmonology Coding Alert

Find out which modifier Medicare prefers you not use.

Many coders often find themselves in a tight spot when coding multiple procedures on a given date. Whether the second code should take a modifier 51 or 59 consumes a huge part of their dilemma. CPT states that the second code would take a modifier 51 if the classifications are different, but what about if the anatomic groups are different?

Don't pull your hair out just yet if you're faced with the same problem. The following do's and don'ts should guide you on the correct usage.

Do: Reserve Modifier 51 For Specific Procedures Only -- But Never For Medicare

When you use a modifier, you wave a flag to the insurance company advising them that the service you're reporting is different. Each modifier's purpose is to tell a specific story that will redefine your service.

Appending modifier 51 (Multiple procedures) to the second or third procedure tells the payer that you did multiple procedures in the same operative session. One way you can look at modifier 51 is to think of it as an informational-type modifier for use on the second, third, etc., surgical procedure performed on the same day. In fact, Medicare does not want you to use this modifier at all. Processing claims electronically allows the carrier to recognize when your physician performs multiple procedures and automatically make the necessary reduction in payment. However, some smaller payers may require the use of this modifier. Before you submit your claim, you should contact your insurance carrier and ask which method it would prefer when reporting multiple surgical procedures.

Example: The pulmonologist performs a bronchoscopy (31622, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) and sees what appears to be lung cancer in the right upper lobe airways. He performs a bronchial biopsy (31625, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy[s], single or multiple sites) of the lesion, and a brushing (31623, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings) in the same area. To determine if the cancer has spread to the lymph nodes, he performs a transcharinal needle aspiration in the trachea.

Code it: On your claim, you would report 31625 (with biopsy) and 31623-51 (with brushing or protected brushings). Modifier 51, in this case, indicates that multiple procedures (the biopsy and brushing) are performed at the same setting.

Remember, codes with modifier 51 attached will usually reimburse for half the normal amount since most insurance companies have adopted Medicare's policy of paying 50 percent for multiple procedures. This occurs whether or not you append modifier 51. Bronchoscopic services are reimbursed differently. You should pay these services according to the multiple endoscopy payment rule, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia. This allows 100 percent for the highest valued procedure (which includes the rate for the primary diagnostic procedure code, 31622). Each subsequent procedure rate (which is inclusive of the rate for 31622) is provided, less the monies associated with 31622, she explains.

Don't: Ignore 'Special Circumstances' For Modifier 59

While you should not expect modifier 51 to effect whether or not the service gets paid, modifier 59 (Distinct procedural service) can actually effect how a claim is reimbursed. Modifier 59 tips off the payer that certain performed services are not normally done together, but an exception is appropriate in a particular case. This case "may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day by the same physician," states the CPT Manual.

Warning: Don't use modifier 59 when another already established modifier is appropriate. According to the CPT Manual, "Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

Modifier 59 is considered the "unbundling" modifier, allowing the procedure to bypass Medicare's CCI edits. When appending this modifier, your documentation should clearly indicate that the service was not part of a more comprehensive procedure. Many payer edits and audits now focus on the appropriate use of modifier 59. Do not use this to routinely unbundle services.

As in the example above: The pulmonologist performs a bronchoscopy and sees what appears to be lung cancer in the right upper lobe airways. He performs a bronchial biopsy of the lesion, and a brushing in the same area. However, to determine if the cancer has spread to the lymph nodes, he performs a transcharinal needle aspiration in the trachea.

As above, you would report 31625 (with biopsy) and 31623-51 (with brushing or protected brushings), but also include 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy[s], trachea, main stem and/or lobar bronchus[i]) on your claim. CPT 31625 is considered a component of 31629. Append modifier 59 to 31625 to illustrate that the biopsy was taken from a site separate from the needle aspiration. This is an appropriate use for modifier 59.