Wiki Billing unlisted procedures with modifiers

[sabsco]

Can anyone help me with this? I'm trying to bill unlisted procedure 41599 with a 51 and a gc modifier to medicare. Our scrubber has held the claim because of these modifiers. I thought I remembered reading somewhere that modifiers are not added to unlisted procedures, because documentation is required to get the procedure paid anyway. Any guidance is greatly appreciated. If you have links to written guidelines, those are appreciated as well.

 

[sabsco]

Unlisted Procedures

Can anyone help me with this? I'm trying to bill unlisted procedure 41599 with a 51 and a gc modifier to medicare. Our scrubber has held the claim because of these modifiers. I thought I remembered reading somewhere that modifiers are not added to unlisted procedures, because documentation is required to get the procedure paid anyway. Any guidance is greatly appreciated. If you have links to written guidelines, those are appreciated as well.

I'm still hoping for any answers to the above question???

 

[ollielooya]

Since you asked for "any guidance"....
From what I understand your scrubber may be holding your claim because it is not necessary to add modifier 51 for a MCR claim. Hopefully you'll get some more input from vets on here. I do not like to see unanswered posts.

Hopefully, others will jump in...

Suzanne E. Byrum CPC

 

[lisaevans]

It's been my experience that Medicare appends the -51 modifier internally. I pulled this excerpt from the CMS site:

Modifier 51 Fact Sheet
Medicare does not recommend reporting Modifier 51 on your claim; the processing system has hard-coded logic to append the modifier to the correct procedure code.

Definition:

Multiple surgeries performed on the same day, during the same surgical session.
Diagnostic Imaging Services Subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider

Appropriate System Usage:

When both diagnostic procedures have an indicator of "4" in the Medicare Physician Fee Schedule Database (MPFSDB) "Mult Surg" column and both diagnostic procedures have the same "Diagnostic Imaging Family Indicator" in the MPFSDB
When the same physician performs more than one surgical service at the same session.
When the MPFSDB indicates a "01-11" in the "Diagnostic Imaging Family Indicator" column.
When both surgical procedure codes have an indicator of "2" in the MPFSDB "Mult Surg" column.
Append modifier 51 to the surgical procedure code with the lower physician fee schedule amount.
Append modifier 51 to the diagnostic imaging procedure with the lower technical component fee schedule amount.

Inappropriate System Usage:

Do not use with designated add-on-codes.
Do not report on all lines of service.

Additional Information:

Medicare pays for multiple surgeries by ranking from the highest physician fee schedule amount to the lowest physician fee schedule amount.
100% of the highest physician fee schedule amount
50% of the physician fee schedule amount for each of the other codes
Medicare will forward the claim information showing Modifier 51 to the secondary insurance.
Multiple surgery pricing logic also applies to assistant at surgery services.
Multiple surgery pricing logic applies to bilateral services (modifier 50) performed on the same day with other procedures.

Hope this helps!