Wiki Does modifier 51 effect payment?

[rbassett]

If you add modifier 51 to a claim with multiple procedures to Medicare (yes, I know Medicare doesn't want you to use them, but say someone did), will Medicare reduce the payment of the additional procedures by putting into effect the Multiple Procedure Payment Reduction rules?

Example:
67228-RT = 100% payment
67028-51,LT = 50% payment

vs

67228-RT =100% payment
67028-LT =100% payment


I always thought modifier 51 was just an informational modifier that some insurances required and didn't trigger payment reductions, but I am being told differently.

Thanks in advance!

 

[CodingKing]

Most modern claims processing systems will see the modifier 51 and automatically reduce. My previous employer who uses trizetto products (used by a many major payers), has modifier discount tables which applied the reduction with the presence of modifier 51. If mod 51 was on the wrong line it would also move it to the correct one. If its not applied at all it will apply the modifier to the claim.

 

[mhstrauss]

If you add modifier 51 to a claim with multiple procedures to Medicare (yes, I know Medicare doesn't want you to use them, but say someone did), will Medicare reduce the payment of the additional procedures by putting into effect the Multiple Procedure Payment Reduction rules?

Example:
67228-RT = 100% payment
67028-51,LT = 50% payment

vs

67228-RT =100% payment
67028-LT =100% payment


I always thought modifier 51 was just an informational modifier that some insurances required and didn't trigger payment reductions, but I am being told differently.

Thanks in advance!

Yes, modifier 51 causes a 50% reduction in payment.

 

[ellzeycoding]

Let's clarify a couple of points here.

1. Most carriers add modifier 51 for you automatically and don't require you to add it.

2. Modifier 51 has to do with the multiple surgery reduction rule. Most carriers calculate the payment reductions for you. How can you tell? The service with the highest RVU is paid at 100%. The other procedures (if subject to multiple surgery reduction) are reduced 50% and so forth. Some codes like add-on codes aren't subject to the multiple surgery reduction rule.

3. If you incorrectly apply it, most carriers won't automatically reduce that payment for you (inappropriately) unless the code is required to be reduced according to the payment edits.


Bottom line, don't worry about modifier 51 unless you have one of the very few "odd" carriers that want you to add it on the claim before submission. These are few and far between.