Pulmonology Coding Alert

*When you list two or more modifiers for one procedure, report modifier -99 (Multiple modifiers) to alert the insurer that more than one modifier applies to this code (for example, 31625-99). Include the actual modifiers used (-51, -59) in the narrative portion of the electronic claim.

Some insurers do not require or do not recognize modifier -99. In this case, you can report the modifier that primarily applies to the code (such as -59). Reporting the services as 31628, 31625-59, 31623-59 and 31624-51 is not wrong. Some insurers do not even recognize modifiers -51 or -59 because they will only pay for one procedure code per family, per date of service. In the case listed above, certain insurers will only pay for the highest-valued procedure (31628), indicating that the remainder of the services are integral to the primary procedure. Nonetheless, reporting all of the services as listed above is important to accurately capture all of the physician work involved.

This information is useful for different reasons. It may help operationally to allocate staff or equipment or to value the "primary procedure" at a higher rate in future contract negotiations with insurers because the payer considers other procedures (and their inherent extra work) included in the primary one.

At any rate, failure to report modifier -51 should not have a negative monetary impact on a claim. The insurer should still pay the claim at the same rate as if you reported modifier -51. Reimbursement for endoscopy procedures follows multiple-endoscopy payment guidelines: 100 percent of the highest-valued procedure plus the difference between the allowable reimbursement for the next-highest-valued procedure and the base endoscopy code. Reimbursement for all other types of procedures (that is, procedures other than endoscopies) is either 100 percent of the allowable reimbursement for the highest-valued procedure, 50 percent of the allowable for procedures two through four. For certain insurers, reimbursement can be 100 percent of the allowable reimbursement for the highest-valued procedure, 50 percent of the allowable for the second procedure, and 25 percent of the allowable for procedures three and four. Any procedure after the fourth requires manual (meaning paper) review by the insurer.