Coding Consult

December 3, 2004

Reporting related codes

If you answered Yes to either of these questions, you may not be taking advantage of situations where you can use modifiers-59 and-51.

Modifier-59 (distinct procedural service) is "used when multiple procedures in the same code areas are performed at the same time," says Linda Parks, a coding specialist in Marietta, GA.

If you don't use modifier-59 on the above example, you'll most likely receive a denial from the insurance company stating that 12001 is bundled into the more-extensive procedure, 12042. The modifier lets the insurance company know that although the codes are related, the doctor performed the procedures on distinctly different areas, and they should be reimbursed separately.

Code order matters Because the higher the relative value units, the more you'll be paid for the procedure, always attach modifier-59 to the code with the lower RVU. The total nonfacility RVU for 12042 is 6.16; while the total nonfacility RVU for 12001 is 3.86.

What should you do if you're stuck on whether you should bill codes with modifier-59? You'll need to check the National Correct Coding Initiative edits (see http://www.cms.hhs.gov/physicians/cciedits/default.asp?). If the codes you're reporting have indicators of "1" next to them, this means you can append the modifier to bypass the edit. If the code has an indicator of "0," you can't bypass the edit. The NCCI edits change quarterly, so make sure that you keep abreast of updates.

Increase your modifier-59 reimbursement rate by using-59 only when absolutely necessary. Many private payers don't require a modifier for multiple-procedure scenarios or don't recognize-59 as a legitimate modifier. Check with your individual payers to see if modifier-59 is necessary when reporting multiple-procedure claims. Then, chart each carrier's policies on-59 so you know whether or not to use it the next time you file a claim. Doing so will streamline your claims submissions.

Modifier-51 is informational When you treat a patient who requires multiple procedures, include modifier-51 (multiple procedures) on your claim. Modifier-51 is an informational-type modifier, for use on the second, third, fourth, or fifth surgical procedure performed on the same day.

For example, a patient presents with a pair of benign lesions on her left leg-one, 0.8 cm and the other, 2.2 cm. You shave both lesions. You should report 11303 (shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm) and attach modifier-51 to 11301 (. . . lesion diameter 0.6 to 1.0 cm).