modifier 51 vs 59

[Chill74]

I work for an orthopedic surgeon , he billed a 28485 and 12041 , with modifier 59 attached to 12041 and it was denied (inappropriate modifier with procedure code), any thoughts on if it should have been modifier 51?

 

[amyjph]

It depends. There is more going on here.
Was the repair done at the site of the open treatment of the fracture? If so the closure is included. Was there another open wound somewhere else on the foot which was closed? Are they looking for an X modifier? Was there another modifier attached to the 12041 such as a toe modifier (T) but the procedure wasn't done on a phalanx?

 

[podcoder70]

Going along with Amy's comment...51 modifier is rarely added by the provider/coder. It is a modifier that the payer adds in their system. There are only a few plans, most are Medicaid, that want the coder/provider to add the 51 modifier. Amy is correct when she suggests that you may be unbundling the 2 codes. Take a look at the CCI edits for these 2 codes. If they were performed on the same site, they are bundled together and only the 28485 should have been coded.

 

[amyjph]

Going along with Amy's comment...51 modifier is rarely added by the provider/coder. It is a modifier that the payer adds in their system. There are only a few plans, most are Medicaid, that want the coder/provider to add the 51 modifier. Amy is correct when she suggests that you may be unbundling the 2 codes. Take a look at the CCI edits for these 2 codes. If they were performed on the same site, they are bundled together and only the 28485 should have been coded.

Agree, 51 modifier is rarely used at this point.

 

[tjuntunen1]

You also need to make sure a 59 modifier is allowed to be used for the denied code.