This coding expert answers common coding questions to help you run a more efficient practice.
A s you know, there are many modifiers that you use daily in billing insurance claims to insurance carriers. There are the E/M modifiers such as -24, 25 and -57. There are post-operative modifiers (e.g., those that are only applied if you’re billing for services in the post-operative period) such as -24, -58 and -79. There’s also what I call the same-day modifiers. These are modifiers that are used when multiple surgical services are performed on the same date of service, certain bundling rules apply, and the claim needs to be unbundled for purposes of avoiding denials and getting paid properly. The most commonly used same-day modifiers are -51, -59 and -76 — with -59 reigning supreme as the king of same-day modifiers. Of course, same-day modifiers can (and frequently are) also used with the other modifiers such as -58 and -79. The -51 Modifier -51 Multiple Procedures: When multiple procedures, other than evaluation and management services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier -51 to the additional procedure or service code(s) or by the use of the separate five digit modifier 09951. Note: This modifier should not be appended to designated “add-on” codes. (e.g., 11101, 17003). When using the –51 modifier, remember: 1. This modifier is used only for surgical services. (Most surgical dermatology services start with a “1.”) 2. Most carriers, including Medicare, no longer require this modifier. The carrier will attach the modifier at the time of claims adjudication (processing). Don’t use the -51 modifier unless you are specifically instructed to do so in writing by a contracted carrier. 3. The modifier isn’t an indicator of whether the procedures listed are related or unrelated. The -51 can be used if the services billed are related to one another (such as 11402 and 12031 — excision and repair of one benign lesion) or unrelated services (such as a biopsy of the back — 11100, and a destruction of an actinic keratosis lesion of the forehead — 17000). Don’t confuse this with the -59 modifier. • Carriers that don’t require the -51 modifier. For Medicare claims, you don’t need to apply the -51 to surgical services. Medicare attaches the -51 modifier during the claims adjudication process. Don’t use this modifier unless you have carrier-specific guidelines for its use and application. New Jersey Medicare, for example, requires the -51 modifier, but only in limited scenarios. Many insurance staff members are mentally “hooked” to this modifier, believing if they don’t use it, the claim will be denied. But, it will quickly become apparent that non-use of the claim results in the claim being paid exactly the same way, except for those carriers that provide written instructions requiring its use. • Carriers that require the -51 modifier. If the carrier you bill requires you to use the -51 modifier, it should be applied to all surgical services except the one with the highest relative value units (RVUs). Also, the -51 modifier shouldn’t be appended to add-on codes. (See Appendix D on pages 434 of the 2003 CPT book.) When determining the actual average cost of a CPT code, be sure to use a nationally accepted conversion factor and RVU, such as those established by Medicare. Some physicians determine their own charges for CPT codes that are inconsistent with nationally accepted payments for the code. This could result in your staff putting the -51 modifier on the highest reimbursed CPT code: thereby forcing the carrier to reduce your highest CPT code and pay 100% of CPT codes with lesser RVUs. The –59 Modifier -59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that aren’t normally reported together, but are appropriate under the circumstances. This 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 performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used in place of modifier -59. Only if there’s not a more descriptive modifier, and the use of modifier -59 best explains the circumstances, should modifier -59 be used. Modifier code 09959 may be used as an alternative to modifier -59. Tips for Using the –59 Modifier 1. It’s used to unbundle same-day surgical services. 2. For Medicare claims the key to knowing/determining which CPT code requires the -59 modifier and which one does not is the Correct Coding Initiative manual. On January 1, 2003, Version 9.0 went into effect. The manual consists of three sections; the narrative, the comprehensive table, and the mutually exclusive table. These three sections will guide the coder to the appropriate use of this modifier for Medicare claims. Reference the lists to appropriately use this modifier and avoid abuse or carrier fraud. (The Correct Coding Initiative lists are updated quarterly by the Center for Medicare and Medicaid Services (CMS). Dermatology-specific versions are available in print form or via a computer program from the Inga Ellzey Practice Group by calling (800) 318-3271.) Most commercial, non-Medicare carriers don’t recognize the -59 modifier. United Healthcare is one of the few carriers that will recognize the -59 modifier and follows the same guidelines as Medicare. 3. Use this modifier in instances where it’s necessary to indicate that a procedure or service was distinct or separate from other services performed on the same day. Examples include the following: • a different session or patient encounter • a different procedure or surgery • a different site or organ system, separate lesion • a separate incision/excision a separate injury (or area of injury). In any of these cases, the use of the modifier will help prevent erroneous claims denials. 4. The medical record must reflect that different lesions were treated or unrelated surgeries performed. 5. The modifier is attached to the CPT code not the ICD-9 code. 6. This modifier does not replace other modifiers that may be used in combination with or instead of -59. 7. This modifier may be used with other numeric modifiers when appropriate, such as -51, -58, -79, etc. Note: Don’t use the -51 unless you have written instructions by your carrier to do so. It’s no longer required on claims for most insurance carriers. 8. Don’t use the -59 modifier on E/M visits (services that start with a “99”). 9. When checking the correct coding initiative table, access the indicator codes. Here’s what they mean: • Zero indicates that there are no circumstances in which a modifier would be appropriate. The use of the -59 modifier will not be appropriate. If appended, the bundled code will still be denied. • One indicates that a modifier is allowed in order to differentiate between the service provided. The use of the -59 modifier on the component code will allow an override of the computer edit and therefore result in payment. Be sure that the -59 modifier is only appended if the bundled pairs are unrelated services. 10. The 2003 Medicare Correct Coding Initiative bundles all excision codes (11400 to 11646) into the adjacent tissue transfer codes (14000 to 14300). This policy applies to both Medicare and non-Medicare carriers. CPT states that the excision is included in the payment for the flap (adjacent tissue transfer). Therefore, no excisions may be billed when the defect requires an adjacent tissue transfer closure. A -59 modifier must be attached to an excision code if an excision is performed on the same date of service as a flap and the excision represents a different lesion. The appending of the -59 to the excision lets Medicare know this surgery is unrelated to the flap. How the -59 and -51 Modifiers Differ The two modifiers perform different functions. The -51 modifier merely indicates that multiple surgical services were provided even though all the procedures billed could be related. In instances when multiple surgical services are billed on the same date of service, the -59 modifier is used to indicate that the services are unrelated or represent a different site, lesion or encounter. Exercise caution when appending the two modifiers for Medicare claims on the same date of service. When a carrier requires the use of the -51 modifier it must be used on the service with lower Relative Value Units (RVUs) while the -59 is attached to the service in the second column of the two lists; Comprehensive Table and Mutually Exclusive Table. Sometimes, the service in the second column may be the service with the higher RVU. For example when billing 17000 and 11100, the -51 would be applied to the 17000 since the RVU for 17000 is less than 11100. For Medicare, you would bill 11100 with the -59 modifier and 17000 with the -51 modifier. The –76 Modifier -76 Repeat Procedure by Same Physician: You may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier -76 to the repeated procedure/service or the separate five-digit modifier code 09976 may be used. Keep in mind the following points for this modifier: • Medicare carriers no longer allow clinical laboratory procedures to be billed with -76. • The -QR alpha modifier is now required for repeat labs services for Medicare claims. • Check your local carrier for instructions regarding the use of this modifier. Another point to remember is that modifier -76 is frequently applied to laboratory services (for non-Medicare claims). Here’s an example: You did a wet mount to rule out scabies on a non-Medicare patient. The first specimen failed to show any parasite. The test was repeated from another area of the body. You bill CPT code 87101 on one line and CPT code 87101 on the second line with a -76 modifier. Note: For Medicare claims, the -QR modifier would be used instead of -76 on the second (repeat) test. The lab service can also be billed in units since the service(s) isn’t subject to the multiple surgery reduction rule for non-Medicare claims. Re-excising a skin cancer due to incomplete margins is not a repeat procedure. (Use the -58 modifier to represent a staged service if performed during the postoperative period. No modifier is needed if the re-excision is performed after the post-operative period is over.) Recent Problems with the –76 Modifier In recent months, many physicians are experiencing problems with their local Medicare carrier regarding the use of the -76 modifier. Claims that were paid properly in the past are now being denied. The change in policy may be due to confusion between Medicare language (as published in a Medicare program memo (Transmittal No. A-00-73, dated Oct. 5, 2000) and the CPT definition of the -76 modifier. The Medicare memo of Oct. 5 specifically states that -76 is “used to indicate that a procedure or service was repeated in a separate operative session on the same day by the same physician” while CPT 2003 states that -76 is used when “a procedure or service is repeated by the same physician subsequent to the original service.” This CPT definition seems to imply to Medicare Medical Part B directors that “subsequent to the original service” means the next day or later. It doesn’t. Until the carriers, who are either eliminating the use of -76 or incorrectly denying claims, correct their policies and reprogram their computers, physicians and their staff should keep close vigil on claims processed with -76 to assure proper payment. If a denial should occur, carefully check the local carrier Web site for possible billing solutions or contact the local Medicare Part B Medical Director personally. Many Part B directors now have e-mail addresses or fax numbers published. Keeping on Top of Changes These guidelines should provide some substantive guidance for the proper use of these modifiers. However, remember that many commercial carriers don’t adhere to or correctly follow CPT guidelines and that policy changes occur almost daily. Close monitoring of carrier bulletins, Web sites and billing messages on EOMBs (explanation of medical benefits) can help your practice.