Wiki Modifier 51-My physician assisted

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Jarts

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My physician assisted on a surgery. The codes billed out by the primary surgeon include a modifier 51 on the PRIMARY procedure. I questioned their use of mod 51 as I believe it will reduce payment on the prime procedure or will be kicked out as unable to process. I was told that their certified coder says they need to use the mod 51 on the prime procedure for reporting purposes to Medicare. What am I missing here?? Isn't this completely wrong?:confused:
Julie
 
Thanks for confirming, Rebecca. It doesn't make sense to me that a certified coder would think that was correct coding. They don't seem inclined to change it, though. As an assist, do you think I should bill it correctly as I see it to be?
Generally, we try to bill out exactly as the primary surgeon as far as order of dx codes, etc in order for our claim to match up with the primary surgeon.

What would you do? I am coming across many issues (errors in coding) as the assist to this particular primary surgeon and we assist with him a lot. This includes incorrect CPT codes, dx codes, POS. Should I just code it correctly as I see it and then...
how do I appeal on the other end if our claim is denied for not matching the prime surgeons?
 
Jarts said:
Thanks for confirming, Rebecca. It doesn't make sense to me that a certified coder would think that was correct coding. They don't seem inclined to change it, though. As an assist, do you think I should bill it correctly as I see it to be?
Generally, we try to bill out exactly as the primary surgeon as far as order of dx codes, etc in order for our claim to match up with the primary surgeon.

What would you do? I am coming across many issues (errors in coding) as the assist to this particular primary surgeon and we assist with him a lot. This includes incorrect CPT codes, dx codes, POS. Should I just code it correctly as I see it and then...
how do I appeal on the other end if our claim is denied for not matching the prime surgeons?
Click to expand...

I would share your concerns with your manager. I would collect your proof and present this information to them. As an advocate for my providers, I try to ensure that their billing/coding is as accurate as possible. If I discover discrepensies/errors, they need to be addressed and corrected. Essentially, your providers are trusting you with this information. In light of RAC, no one can afford to become complacent. Since your surgeon assists the primary surgeon frequently, I'm sure they'll both appreciate your positive feedback. It's not an easy task but It's the most ethical/honest approach.
 
mitchellde said:
I agree with Rebecca, well said!
Click to expand...

Thanks for your replies ~ I have contacted the primary surgeon's office repeatedly and today's response was "BUT SOMETIMES IT'S A HIT AND MISS AS I'M SURE YOU KNOW." They don't seem overly concerned:(
 
trvlingal1

When billing surgery to Medicare Part B, the primary procedure is the procedure with the highest Fee Schedule amount - and does not require Modifier 51. However, even if you do not append Modifier 51 to the secondary surgery(s), Medicare's Claims Processing System will automatically append Modifier 51 to any surgical procedures it considers secondary. For an assistant surgeon, all that is required is the modifier that depicts the assistant (i.e., 80, 82, AS, etc.) and any informational modifiers (i.e., rt, lt, etc.)
 
Right! I know we don't have to append mod 51 at all on any of the secondary procedures with medicare, but we def don't want to append it to the first procedure. I figure it "might" get processed correctly, BUT my feeling is they will either accept it and reduce the prime procedure payment or it will just get kicked out as an inappropriate modifier making it unable to be processed.
This is simply one of the least of my problems with their coding...
just frustrated.
 
I know it's frustrating. These type of "issues" do have a way of exposing themself. Whether it be from a reduction in revenue due to incorrect posting, high A/R due to incorrect coding or suddenly a request for medical notes due to inconsistent, dual physician reporting of charges. Keep paper trails of your recommendations and their responses.....
 
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