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Modifier 59 & 51 on same cpt

nhenderson

Networker
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63
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Some of our billers have started using a modifier 59 to indicate a distinct procedure and using a modifier 51 on the same cpt code. To me the modifier 51 is not appropriate. Is this a proper use of the modifiers? Example 23410, 29826-59-51-RT, 23120-51-RT
 

jmcpolin

True Blue
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841
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Midvale, UT
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most Medicare carriers do no recommend using the 51 modifier because they automatically reduce the second or more procedures.
 

nhenderson

Networker
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63
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What if the carrier is not medicare. Is it appropriate to have a mod 59 and 51 on the same cpt?
 

jmcpolin

True Blue
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841
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Midvale, UT
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I personally don't ever use the 51 modifier because I have yet to see a payor not reduce the second procedure. But I found this online:

Occasionally, you can use both modifiers at the same time. For example, the FP performs a biopsy of a lesion on a patient's arm and excises a benign lesion on the neck during the same visit. You would report 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and 11420 (Excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less) and append modifier -51 and modifier -59 to the biopsy code.


Modifier -51 is attached to the 11100 because it is the lesser-valued procedure, while -59 is attached to that code because the biopsy is a component of the excision. The -51 indicates that two procedures were performed, and the -59 indicates that they were performed on two separate lesions. “Without the -59, the payer could assume that both biopsy and excision were done on one lesion, and they wouldn't pay for that,” Newby says. The use of both codes illustrates a multiple procedure that is normally bundled but should be unbundled because it was performed on two separate sites.
 

ollielooya

True Blue
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900
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Everett, WA
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...another interesting thread which brings up the question. If these two modifiers ARE supported ---in which order would they be sequenced? Would it even make a difference? -Suzanne E. Byrum CPC
 
Messages
4,466
Location
Milwaukee WI
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No real need to use both

There is no real need to use both - EVER. Doing so is unnecessary.

The -59 modifier tells you that this is a distinct procedure from the first procedure (for example two distinct lesions).

The -51 modifier would tell you that you performed a second (or third or fourth...) procedure at the same time as the first.

Well, if you have a distinct procedure, don't you already know that you had more than one procedure?

By the way ... the -59 modifier does NOT mean that you won't get a multiple surgery discount on the second procedure. You will still have a reduced payment because you will not be duplicating your pre- and post-operative care.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

JJackson506

Guest
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Some of our billers have started using a modifier 59 to indicate a distinct procedure and using a modifier 51 on the same cpt code. To me the modifier 51 is not appropriate. Is this a proper use of the modifiers? Example 23410, 29826-59-51-RT, 23120-51-RT
The use of one or both modifiers is dependent on the carriers preference. With Medicare you never need the -51, their system will automatically make the reductions. Many of the other carriers also do not require the -51, however, some do, you should ask the question to your carrier. Everything is carrier specific and you want to do what the carrier requires as far as the -51 and -59 in order for your doctor to be paid and to lower claim rejections.
 

ollielooya

True Blue
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900
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Everett, WA
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I understand what you mean by payer specific, because we have one payer that requires modifier 51 on the claims, or it WILL not process the particular line items, even if we use modifier 59. They WANT modifier 51 appended after modifier 59! The majority of our 31 payers don't want it, so we don't, but this one particular payer is cranky if we don't. And it is not a little company either!! ---Suzanne E. Byrum CPC
 
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