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59 and 51

jdibble

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Our surgeons are now being required to code all of their work themselves including modifiers and we are auditing them and guiding them in correcting their errors. Since they are required to pick the correct modifier as well as the code, can anyone help me with an easy way to tell them the difference between the 51 and 59 modifiers - and when to use one over the other?

I am having a hard time putting this into a simple way for them as I am always confused too as to which one to use too! I myself have access to programs that give me the CCI edits, however they do not have this access - nor would they probably want to have to use any either! :confused:

Thanks for the assistance! :)
 

LindaEV

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Local Chapter Officer
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51 is used for multiple procedures. 59 takes its place when CCI edits tell you you cannot bill the codes together, but your documentation proves they are separate.

They will not know the CCI edits if they do not have access to them, or look them up. I get the coding rule, but for the surgeons to also have to take the time and choose modifiers? Seems silly to audit them on something they don't have the correct tools for.
 

mitchellde

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How can they know they need a modifier without checking the CCI edits? JMO but requiring the physicians to do the coding is not the most efficient way to do things.
the 51 modifier only conveys that the second and subsequent procedure were performed in the same session, most payers do not want you to use this modifier anymore and several will auto add it, its purpose is to convey to the editor to discount this procedure.
the 59 modifier is used when the procedure it is applied to is either a duplicate procedure performed on a different area or it is a component of a comprehensive procedure that is being performed on a different site separate organ or via a separate incision, or the procedure is mutually exclusive to the other procedure and is being performed on a separate site or organ or via a separate incision.
It is impossible to know from looking at 2 or more codes which ones will be bundled and which type of edit they will be. Also the edits are updated/revised every quarter so they must always be looked at to determine if a modifier is needed.
I wish you luck in this but I cannot see any doctor I have ever worked with taking the time necessary to to this, when will they have time to see patients??
 

jdibble

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Thanks Debra and Linda for your answers.

I understand what you are saying and believe me I have heard this all from my docs too! CPT isn't as bad for them, but they are also expected to choose the correct ICD-9 codes! My hospital merged with a very large entity and my hospital based physician practice now needs to meet their requirements and all of our doctors are required to do all of their coding and need to be at a 5% error rate to be released from 100% review. Keeps me busy - job security, but it is really taxing trying to explain all of these things to the doctors, listen to them complain and also get my work done!

Thanks again!
 

mitchellde

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such a bad decision IMO! If you could only convince those in authority as to how much they are really losing here, in real dollars. If the provider does this work then they paid for that time then the coder goes over it to insure it is correct (or not) and they paid for that time, and how many do not pass for payment the first time and come back and must be reviewed again and they pay for that time. If you convince them that the doctors time is better spent treating patients and documenting, and nothing eles,... then let the coder do their job and do it with all the right tools which includes the complete documentation not a superbill, you would see fewer front end rejections and the end result will be quicker revenue and less staff needed to work the back end. I have actually performed this little experiment many times in facilites and doctor offices always with the same result.
 
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