Neurosurgery Coding Alert

Question: We have multiple claims coming back from Medicare-Palmetto GBA with modifier 51 added to the primary procedure instead as the secondary as we submitted (e.g., 22612, 63047-51; submitted: Medicare 22612-51; 63047). The Medicare rep's explanation is "From 2012, you do not submit codes with modifier 51, We would apply to the code which is going to be with multiple procedure discount." This reduces the payment by at least $500.00. How do we deal with this situation?

Arizona Subscriber

Answer: Modifier 51 has been a no-no for several years now.  It is true that Medicare carriers apply the modifier 51 to the "appropriate" secondary code, which may or may not agree with your "secondary" code. Medicare has typically applied the reduction to the lesser valued code in their fee schedule to all codes which are subject to the multiple procedure rule.

In the coding combination provided, 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) is the higher valued code, and therefore the 51 (Multiple procedures...) modifier should be correctly applied to 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis], single vertebral segment; lumbar). You may try appealing the application of the reduction on the higher valued code. It is surprising to know that they are not reducing BOTH services, since you add it to one and they add it to the other.  If this is what is happening, you will have to submit corrected claims omitting the 51 modifier.