Wiki Modifier 51 - troubles

[dani5042]

Hello,

I am a new member and have not seen this question in the previous threads. I am having problems this year with Medicare appending our procedures with Mod 51 and reducing our payments on 2 codes specifically.

The first is Pacer Generater Implant/Explant. We bill it as 33233-59 & 33213 We receive payment back with full payment on 33213 and reduced payment on the 33233-59 where they appended this charge with the 51 modifier. I am confused is the 59 modifier not supposed to separate this as a distinctive procedure and there for not a multiple surgery that gets ranked lower and paid at 50%?

The 2nd one is the 93543 (LV/ LA Angiography) in a cath, this is an update in 2008 that is no longer modifier 51 exempt and no matter how we bill it it gets reduced 50%. I would appreciate this in layman's terms.

thanks
Danielle B.
Greensboro Cardiology

 

[Davistm]

Appending modifier 59 to code 33233 is unnecesary and inappropriate. Codes 33233 and 33213 are neither mutually exclusive nor bundled - they are payed separately. No modifier is necessary.

In general, modifier 59 helps decide if you will be paid for a specific code or not. It doesn't impact the amount you are paid. CMS assigns all surgical codes a Multiple Surgery Indicator [refer to the Medicare Fee Schedule]. Codes with indicators of 1, 2 and 3 will have payment reduced when billed together. The reported surgery codes are rank ordered by the fee schedule amount. The highest ranked code is paid at 100%. Each successive ranked code is paid at 50%. [Modifier 59 has no impact].

In layman's terms - that's the way it is. Don't get cute with your billing trying to avoid multiple surgery reductions.

Terry

 

[Lisa Bledsoe]

I have a similar issue with our new Medicare contractor - they are adding modifier -51 to CPT codes in which CPT states NOT to add modifier -51. Thus, they are reducing our reimbursement by half. We did not have this problem with our previous Medicare carrier. Specific codes they have added modifier -51 to are 33233, 93510, and 93545. We have never used modifier -51 OR -59 on these codes. Any advice/help will be MUCH appreciated!!

 

[Davistm]

I'll make two separate replies and try to keep them short. You can reach me direct at tdavis@ocaheart.com.

Code 33233 has a Multiple Surgery Indicator of 2. This means that anytime the code is billed with another code with Multiple Surgery Indicators of 1,2 or 3, the code with the highest RVU will be paid at 100% of the allowed amount. The other code will be paid at 50% of the allowed amount.

Example. MD replaces a dual chamber PM [same pocket, leads re-used]. The codes are 33213 [Multiple Surgery Indicator of 2] and 33233. Allowed amounts are: 33213 - $350.89; 33233 - $222.05. Code 33213 is paid at 100%; code 33233 is paid at 50% [$111.03].

This is logical. RVUs assigned to code 33213 include the surgical creation and closure of a generator pocket. RVUs assignd to code 33233 include the surgical opening and closure of a generator pocket. When a generator is replaced in the same pocket, Medicare reduces code 33233 by 50% so that they do not pay twice for the surgical opening and closure of the same pocket. If the MD has to create a new pocket for the new generator and/or replace one or both leads then your coding will not be 33213 and 33233. For example, the MD removes the old; caps the old leads and emplaces a dual chamber PM in a new pocket. Coding is 33208, 33233 and 71090-26. The point is, modifier 59 is never appropriate for code pair 33213 and 33233 because when billed together they signify that the same pocket and leads were used. If they weren't, the coding will be different.

If there is still some confusion, email me direct and I will give you a toll free number to contact me.

Terry

 

[Davistm]

Part 2. Multiple surgery reductions are a fact of life. You'll have to learn to live with them.

For 2008, CPT was revised to remove the modifier 51 exemption from 18 catheterization codes: 93501, 93505, 93508, 93510, 93511, 93514, 93524, 93526, 93527, 93528, 93529, 93530, 93531, 93532, 93533, 93541, 93542 and 93543. These codes now have a Multiple Surgery Indicator of 2. Again, this means that they are subject to multiple surgery reductions when billed with any codes with a Multiple Surgery Indicator of 1, 2 or 3. [10 EP codes were similarly revised].

What CMS is saying is that in the past we have been overpaid for certain code combinations [multiple surgeries]. They aren't going to recoup any monies, but they are going to stop overpaying.

Terry