Is it 51 or 59?


True Blue
Best answers
Modifier 59 is used to bypass CCI edits when specific criteria is met. 51 is just an indicator that is put on a additional surgical procedures. Is possible you could need 59 & 51 on the same line if both apply. 59 would come first as its a more important modifier. Even if you leave 51 off most payers will automatically apply it.


Best answers
To piggyback off what King said, these modifiers are very different and are used for different but sometimes overlapping situations. Modifier 51 is used on all surgery/medicine codes billed in addition to the main procedure. For example, if my doctor performed a lap. radical prostatectomy as well as a bilatereal pelvic lymph node dissection (BPLND), the prostatectomy (55866) is the main procedure and the secondary procedure, the BPLND, would get a 51 modifier. The 51 is always applied to the procedure with the lower RVU value, and prevents insurance companies from flipping your code order on the claim so they can pay 100% of the allowable on your secondary procedure and 50% of the allowable for the main procedure (reducing what your total reimbursement should be...) under the multiple procedures payment reduction (MPPR) rule. ALWAYS use a 51 where it is needed, and never assume that any privbate insurance company will apply them for you on your behalf - it is in their best financial interest to NOT do so.

Modifier 59 is to bypass CCI edits for two codes that would normally not be billed together but have special circumstances. This modifier is not accepted by all insurance companies since it has been further separated into 4 more specific modifiers. I would recomment doing some research on the X{ESPU} modifiers. A good start would be here with this AAPC article.

Hope this helps!