Wiki -51 vs -59

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awerner

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Can someone please explain the difference between modifer's 59 and 51? Im having a hard time understanding the difference between them and when its appropriate to use one instead of the other. From what I understand 51 has more to do with reimbursement percentage than anything else, maybe im just not understanding? For example, 23472 (total shoulder) and 23430 (bicpes tenodesis) on the NCCI edit states a modifier is allowed to differentiate between services but rejected with a -59. please help!
 
The 51 modifier was created to indicate when a procedure was performed at the same session as another procedure on the claim. it was used to indicate that the procure should be discounted. In todays electronic processing, most payers automatically discount the second and subsequent procedures.
The 59 modifier s used to indicate that the procedure it is attached to should not be considered inclusive to the other procedure(s) on the claim, as you can show separate site or separate incision, or separate session.
 
51 = multiple procedure discounting
59 - Meets criteria for bypassing NCCI Edit.

As stated above many payers will actually tell you not to add modifier 51.
 
If you have 11100 and 11101 (which is an add on code) on the same DOS can you put a 59 modifier on both codes? I am pretty sure you can't but I am seeing it done and I want to double check.
 
trinityvista said:
If you have 11100 and 11101 (which is an add on code) on the same DOS can you put a 59 modifier on both codes? I am pretty sure you can't but I am seeing it done and I want to double check.
Click to expand...

Well, first 11100 needs to be bundled with something according to the NCCI edits.

Lets say you do a destruction (CPT 17110) and a biopsy (CPT 11100) and separate/unrelated lesions.

According to the NCCI edits, modifier 59 (or XS) would be used on the biopsy code to show that they are separate and unrelated lesions/sites.

17110
11100 -59

Now lets say you did two biopsies (CPT 11100/11101) in addition to the destruction.

Medicare and a decent percentage of the carriers don't want modifier 59 on the add-on code (ie., 11101) when the primary code (i.e, 11100) is bundled with another service.

However, there are a number of carriers that DO want it on add-on codes (when the primary code is bundled).

So, depending on carrier preference you bill:

17110
11100 -59
11101

or

17110
11100 -59
11101 -59 (if carrier wants modifier 59 on add-on codes when primary is bundled)
 
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