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Thread: 59 Modifier and RVU's - The spine surgeon did a re-exploration

  1. #1

    Default 59 Modifier and RVU's - The spine surgeon did a re-exploration

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    The spine surgeon did a re-exploration of hemilaminectomy at L5-S1 (63042) and a laminectomy at L3-4 and L4-5 (63047, 63048). I code according to RVU's. 63042 has a higher RVU than 63047. However, 63042 is bundled with 63047. Insurance is denying the 63042 as inclusive. From what I have found on internet, it is not appropriate to put 59 modifier on primary procedure. These procedures are done at different levels, and the surgeon should get paid for them. Does anyone have suggestions about this?
    Last edited by ank3t; 10-05-2016 at 06:46 AM.

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Our practice is also affected by this payment methodology but unfortunatley, I see no way around it. 63042 has work RVU's of 18.61 63047=15.22

    63047 has a payment status indicator 2. Therefore, most carriers will follow the payment policy below:

    Standard payment adjustment rules for multiple procedures apply.

    If a procedure is reported on the same day as another procedure with an indicator of 1, 2, for 3, you will need to rank the procedures by fee schedule (RVU's) amount and apply the appropriate reduction to the secondary codes (100%-50%-50%......)

    Also...I don't see where NCCI edits bundle 63047 into 63042. I would append 51 to 63047. However, the multiple payment reduction will still apply.
    Last edited by RebeccaWoodward*; 04-08-2009 at 11:59 AM.

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