Pediatric Coding Alert

A common modifier -59 scenario in pediatrics involves patients who receive nebulizer treatments and instructions on the same day, says Lee Ann Shumiloff, billing manager for the department of pediatrics at the West Virginia University School of Medicine in Morgantown.

Example: A 5-year-old established patient newly diagnosed with asthma reports with still-worsening symptoms and needs to be checked for medication adjustments. The pediatrician performs a level-three evaluation and management (E/M) service, administers a nebulizer treatment, and then decides that home treatments are necessary for the patient. 

He instructs the patient and his parents about how to conduct home nebulizer treatments before sending the child home.

The claim should read:

This reporting method "works well with some carriers, but not all of them, of course," Shumiloff says.

Hot tip: Increase your modifier -59 reimbursement rate by using it only when absolutely necessary - many  payers do not require the use of a modifier with the previous multiple minor-procedure scenario.

Check with your individual payer to see if modifier -59 is necessary when reporting multiple minorprocedure claims. However, don't be afraid to use it when no other modifier seems apropos, says Catherine A. Hudson, RMA, RPT, of Cumberland Pediatrics PC, in Marietta, Ga.

"Using the -59 modifier when reporting multiple procedures has gotten [our office] payment when any other way [of reporting] could not - especially with Medicaid," she says.

When your physician treats a patient with multiple injuries requiring multiple surgeries, you would include modifier -51 (Multiple procedures) on your claim. While reimbursement rates for codes with modifier -59 attached  vary by payer, expect half the normal reimbursement for codes with modifier -51 attached (most  insurance companies have adopted Medicare's policy paying 50 percent for codes with modifier -51 attached).

Modifier -51 is "an informational-type modifier ... for use on the second, third, etc., surgical procedure performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources.

Example: An 8-year-old established patient reports to the pediatrician with a pair of cuts on her right forearm.  The physician sutures a 2.6-centimeter simple wound on the forearm and makes a separate, complex 2.1-centimeter closure a few inches away on the same forearm.

Report 13120 (Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm) first, followed by 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) with modifier -51 attached to 12002.

The modifier is appropriate because the two procedures are close enough to cleanse, prep, and anesthetize in the same session, Riesser says.

Why? Modifier -51 shows the insurance company that although the multiple procedures were related to each other due to anatomic area, they were separate injuries that required separate treatments.

Warning: Multiple closures on different body sites or of different types (that is, simple, intermediate, or complex) aren't bundled together, so leave modifier -51 off of claims for multiple closures on different sites.

As with modifier -59, make sure to report the code with the highest RVU first when using -51. "Modifier -51 prevents the insurance company from changing the order of your codes, because the most expensive procedure should be listed first," Riesser says.