Question Modifier 51

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8
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When does an ASC append the modifier 51? From my understanding over the last 13 years Modifier 51 is not on the ASC list. Therefore I have never used it. Molina is stating they processed some of our claims incorrectly not using the multiple surgery rule resulting in overpayment. They are stating that I am supposed to use the Modifier 51. I have no idea when to use it or what CPT codes to use it on. For example these are the codes I would normally code.

30520
21026
30930
31231

Can anyone tell me which of these codes would require a 51 modifier?
Also, maybe some articles that either show ASC's aren't required to use it or articles that show when and how to use it in ASC coding.

Thank you,
Brenda
 

Deborah Marsh

Networker
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39
Location
Southern Pines, NC
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Hi - This use seems to be payer-specific. For instance, someone subject to https://lni.wa.gov/patient-care/billing-payments/marfsdocs/2021/2021MarfsChapter32.pdf would see mod 51 listed in there. Even on the physician side, it's not unusual for a payer to not want 51 because they'd rather have software figure it out.

If Molina doesn't have a written policy stating modifier 51 is required for ASCs, the ASC list from the CPT manual seems the most authoritative and convincing source.

Blog posts like https://www.aapc.com/blog/44907-coding-and-billing-multiple-procedures/ and https://www.aapc.com/blog/49616-multiple-endoscopy-rule-examples/ may help with understanding when the rule applies

Have you tried searching the Outpatient Facilities forum? Perhaps it's been covered there. Best of luck!
 
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16
Location
Bakersfield, CA
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Which one of the procedures are they requesting the money back on? That is the one that will need the modifier 51. But, in most cases (at least where I work), the modifier 51 should go on the lesser priced of the two surgical procedures to ensure maximum reimbursement. Molina Medical? Are you in California? Also, what type of payor is requesting this? Private or Medi-Cal?
 
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Which one of the procedures are they requesting the money back on? That is the one that will need the modifier 51. But, in most cases (at least where I work), the modifier 51 should go on the lesser priced of the two surgical procedures to ensure maximum reimbursement. Molina Medical? Are you in California? Also, what type of payor is requesting this? Private or Medi-Cal?

This is for Molina Medi-Cal in California. We bill multiple codes up to about 5 codes at a time for sinus surgeries. Of the 5 codes they are paying all of them at 100% instead of using the surgery rule of 100, 50 and 25.
 
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16
Location
Bakersfield, CA
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I have noticed that there are some Medi-Cal plans that pay way over the normal Medi-Cal allowables. But, also remember, that Medi-Cal does what Medi-Cal wants. They seem to be 5 years behind the rest of how the world bills and pays claims. I am fighting with one of my Medi-Cal payors regarding a modifier TC. Nothing I say or do will get them to change their minds. For Molina, because we bill them as an OOA Medi-Cal payor if we get LA county people moving up here, we will make modifications to how they want the claim coded to get paid. If they are the only ones doing this then, first, I'd give them a call asking why they are doing this. Then, if they won't budge, apend the 51 modifier to the procedure code(s) they are asking for their money back on.
 
Messages
8
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I have noticed that there are some Medi-Cal plans that pay way over the normal Medi-Cal allowables. But, also remember, that Medi-Cal does what Medi-Cal wants. They seem to be 5 years behind the rest of how the world bills and pays claims. I am fighting with one of my Medi-Cal payors regarding a modifier TC. Nothing I say or do will get them to change their minds. For Molina, because we bill them as an OOA Medi-Cal payor if we get LA county people moving up here, we will make modifications to how they want the claim coded to get paid. If they are the only ones doing this then, first, I'd give them a call asking why they are doing this. Then, if they won't budge, apend the 51 modifier to the procedure code(s) they are asking for their money back on.

On the subject of the Medi-Cal issue are you required to bill the UA and UB modifiers on you Blue Cross Medi-Cal claims? Blue Cross Medi-Cal is stating we required to bill with these modifiers. What is the issue you are having with the TC modifier?
 
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On the subject of the Medi-Cal issue are you required to bill the UA and UB modifiers on you Blue Cross Medi-Cal claims? Blue Cross Medi-Cal is stating we required to bill with these modifiers. What is the issue you are having with the TC modifier?
Also, do you bill using the Z-codes and if so which ones? I know there used to be and X code as well. I was just wondering if it had ever been replaced
 
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16
Location
Bakersfield, CA
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Also, do you bill using the Z-codes and if so which ones? I know there used to be and X code as well. I was just wondering if it had ever been replaced
We no longer have Blue Cross Medi-Cal in Kern County. They left our county about 4 years ago. We have Health Net, Kaiser and Kern Family that handle the Medi-Cal plans here if they aren't straight Medi-Cal. Certain codes do require U modifiers. We mostly use U8 and UD. But I work at the county health dept and we have limited services pertaining to communicable diseases and STD screenings and treatment and some family planning services (birth control devices (Nexplanon and IUC insertions)) which are considered surgical.
 
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