Reader Question:
Avoid Modifier -51 for multiple Endoscopies
Published on Sun Aug 01, 1999
Question: On a patient with anastomotic dehiscence, the surgeon performs a laparoscopic right colectomy, laparoscopic ileostomy, and laparoscopic jejunostomy. Code 56348 (laparoscopic intestinal resection) doesnt include an ileostomy and theres no separate code for laparoscopic ileostomies. How do I code for these three procedures when theyre performed as multiple procedures?
Anonymous KY Coder
Answer: To complete the list of laparoscopic codes, there is also one for laparoscopic jejunostomy (56347) Ileostomy is the only one theres no code for, says Jacqueline Leopold, CPC, president of Practice Management Consulting Corp., in Highland Park, IL. The laparoscopic section always lags behind the other sections of the [CPT] book, Leopold says. In the above example, she recommends using code 56399 (unlisted procedure, laparoscopy, hysteroscopy) until a new code is developed. Before assigning an unlisted procedure code, always check with your insurance carrier before submitting the claim to see how they would like it submitted. Some may not want you to use an unlisted code; they may prefer you to use an existing code that is closely related and assign either modifier -52 (reduced services) or -22 (unusual services) to that code (but make sure you receive that request in writing).
Susan Callaway-Stradley, CPC, adds: Medicare and other carriers pay according to whether procedures are in a related family. Using the 56300 series as an example, lets say the surgeon makes an incision and moves the laparoscope around to fix a variety of problems. Medicare will pay the most highly valued one at 100 percent. The second and third procedures will be paid at a rate that is the difference between the 56300 series base code (56300, laparoscopy [peritoneoscopy), diagnostic; [separate procedure]) and the rate for the two procedures. The rational for discounting the payment on the second and third procedures is that the laparoscopic incision had to be opened and closed only once, even though three procedures were performed.
Callaway-Stradley also cautions coders not to use modifier -51 (multiple procedures). Medicare says do not put a -51 modifier on endoscopies from the same family. If you do, they will deduct 50 percent of the payment because of the modifier from the already reduced payment on the endoscopy due to the related-family discount, she says. She adds that commercial carriers may or may not follow the HCFA guidelines, but its a good idea not to use modifier -51, particularly if you dont know how they are going to value the unlisted code (56399); it may end up being the most valuable procedure, and if the -51 is attached, 50 percent of its reimbursement will be withheld.
Instead of -51, modifier -59 (distinct procedural service) may be used to indicate a separate procedure that is not bundled to the other [...]
