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Need help with modifiers.

  1. Wink Need help with modifiers.
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    I need help with modifiers. This is for the surgery center (facility) and not for any individual physician, please let me know if you need additional information, thanks.


    1st patient: DX: RT shoulder 727.00, 840.7, 726.2, 715.91

    CPT: 29827
    29807
    29826
    29824
    29820
    23700

    Which modifier I should use? According to CCI edit 29820 and 23700 are bundled in procedure code 29824.


    2nd patient: DX: 374.10 (Ectopion, both lower eyelids), 709.2 (Scar tissue, LT ear).

    CPT: 14060-LT-59
    15821-E2-E4-50
    67917-E2-E4-50

    Do I need any additional modifiers for 15821 and 67917?

    3rd patient: DX: 527.2 (RT submandibular sialadenitis), 701.9 (multiple skin tags RT upper eyelid), 784.49 (hoarseness).

    CPT: 42330-59
    31515
    11200-E3

    Do I need any additional modifiers for 31515 procedure and 11200 procedure?

    Thank you so much.

    Pragna

  2. #2
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    I will respond on patient #1:

    the 29820 and 23700 should not be billed at all, not even with modifiers. This is clearly a shoulder case and there is no way (coding ethical) to get around that to justify the 59 modifier.

    Hope this helps
    Mary

  3. #3
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    For patient 2 you do not need LT on 14060 nor do you need a 59 since there are no bundling issues. Also I don't believe you need E2 & E4 since you have 50 listed. Adding E2 & E4 is redundent because those procedures are already by description for the lower lid and the modifier 50 shows it was left & right.

    For patient 3 there is no need for modifier 59. Those three codes have no bundling issues so besides the E3 all you would need is modifier 51 on the two lesser procedures.

    Hope this helps!
    Eileen Blankenship, CPC
    Remote Coder

  4. #4
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    Scenario #3---Facilties do not use "51"
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
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    Scenario #3 (again)---based on the description of 11200 (any area), no anatomical modifier is needed.
    Also, just curious....why the "59" on the 42330?
    Karen Maloney, CPC
    Data Quality Specialist

  6. Default
    Quote Originally Posted by magnolia1 View Post
    Scenario #3 (again)---based on the description of 11200 (any area), no anatomical modifier is needed.
    Also, just curious....why the "59" on the 42330?
    Karen,
    Scenario#3 CPT code 42330-59 modifier I have used because to identify that a procedure or service was distinct or independent from the other services performed on the same day.
    Pragna, CPC

  7. #7
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    unfortunately I have to respectfully disagree with Cinnamon

    51 is not a valid modifier for a surgery center setting, that is a physician modifier.

    Also, coding guidelines state that when using a code that references multiple body areas (such as 14060), that identifying (RT/LT) modifiers should not be placed (other than the 59). (Rebecca..do you have those guidelines handy and available to post??)

    Hope this helps
    Mary

  8. #8
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    Quote Originally Posted by cinnamon View Post
    Sorry Mobrt,

    But -51 can be used for a multiple procedure as long it's not a add-on on some procedures and the payor requires it use. So I'm not sure what you mean surgery center. Please clarify what your reference is to.

    The Centers for Medicare and Medicaid Services (CMS) designate which procedure codes are valid for use with modifier -51.

    Codes valid for modifier -51 use are eligible for reimbursement at billed charges OR 50% of the fee schedule amount for the 2nd procedure AND 25% of the fee schedule amount for all subsequent procedures, whichever is less.

    ASCs should not use the -51 modifier on their codes, unless the payor requires its use. When more than one procedure (excluding E&M codes) is performed on the same day during the same encounter by the same physician, modifier -51 should be appended to the subsequent procedures on the physician's claim. The exception to this guideline is if the CPT code is an add-on code, or if it is –51 modifier-exempt.
    To me a "surgery center" is either an ASC or outpatient hospital surgery center, in which the -51 modifier is not approved for. I know that some payors will add these to claims, but we, as coders, should not be applying the -51 modifier to our cases.

    The original poster had indicated that the cases in question were for a "surgery center".

    Hope this helps
    Mary

  9. #9
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    Quote Originally Posted by cinnamon View Post
    As I stated as long as the code is required. I'm a claims examiner also and worked for some of the biggest carriers and if Anthem , say it required you can add a -51 as long it's not a add, sometimes a procedure can be outpatient and not be surgery center. It could be a hospital with same day procedure. But it clear that you can. It best to Privy message. And I wasn't specific to whether it had surgery center or not, I was helping the poster get an idea of how modifier should be and some examples for coding situations. Thanks!!
    The bottom line is:

    51 is not approved, per CPT, for Hospital Outpatient Use (ASC included), per inside over of CPT manual, professional edition, right upper column.

    If a Payor is "requiring" the use of the 51...then I would request their requirements in writing from that carrier to cover yourself just as you would if a carrier asks you to do anything else that would be considered outside of the normal coding guidelines.

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