Primary Care Coding Alert

Modifiers -59 (Distinct procedural service) and -51 (Multiple procedures) have heads spinning, and the convoluted language in CPT offers little relief to coders - but experts say the key to the confusing modifiers is understanding the definition of "distinct."

"Modifier -51 is straightforward; FP coders use it a lot to indicate multiple procedures," says Marie Felger, CPC, an American Academy of Professional Coders (AAPC) certified coding instructor with Joy Newby & Associates Inc. in Indianapolis. "But the -59 is what slips them up. Distinct can mean a lot of things - separate site, separate encounter." Often coders use a -51 when they should use a -59 and vice versa.

Because modifiers -51 and -59 are for surgical procedures, family practices most often use them when dealing with lesion removal and biopsy, Felger says. Use -51 for Multiples "Attaching a modifier -51 tells the insurer that you performed more than one surgical service at the same session," says Joy Newby, LPN, CPC, president of Joy Newby & Associates Inc., a reimbursement consulting company in Indianapolis.

For example, an established male patient presents to the FP with lesions on his chest and hand, and the physician removes them during the same visit. Both 11421 (Excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; lesion diameter of 0.6 to 1.0 cm) and 11401 (Excision, benign lesion, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 0.6 to 1.0 cm) should be billed. Attach modifier -51 to 11401.

"You attach the modifier -51 to the lesser-valued service because the payer will reduce the fee for the code with the modifier, and you want to be paid in full for the more expensive procedure," Newby says. Carriers will usually pay about 50 percent or less of the second procedure. Newby advises coders to bill the full fee for each procedure because usually the payers will automatically reduce the fee with the -51 modifier. Keep in mind that requirements for -51 vary from carrier to carrier. Use -59 to Unbundle Appropriately Attaching modifier -59 to a code tells the insurance company to unbundle two procedures that normally cannot be paid together, says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City. For example, in the morning the FP removes a skin tag from a patient's back. Later that afternoon, the patient returns with a broken right great toe from falling down some stairs. Report 11200* (Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions) and the appropriate fracture care code (e.g., 28490, Closed treatment of fracture great toe, phalanx [...]