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Why is 59 versus 51 sooo confusing?

  1. #1
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    Everett, WA
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    Default Why is 59 versus 51 sooo confusing?
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    Frankly, (and as a new apprentice coder within the past year), I'm still failing to firmly grasp the proper usage of these two modifiers. I've studied and even paid for a modifier course, and have asked my esteemed veterans of many years for their advice, and there is such a variance in answers. Why is this so difficult or is it just me? For example: migraine specialist who has his own office who performs nerve blocks on the same day, such as 64405, 64400 and 64450.
    Wouldn't it be appropriate to use the 51 modifier INSTEAD of the 59 after the 64400 and 64450? Why would one even add the 59 as a modifier of last resort? It does all boil down to what the insurance carriers want it appears despite what one may learn from textbook learning, MCR CCI edits/studies and guidelines . What made all of this "click" for you? ---Suzanne

  2. #2
    Location
    High Point, NC
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    Think of modifier 59 as the "unbundling" modifier. Use this when the CPT codes you are billing are bundled due to CCI or ME edits and you need to unbundle them. Just remember that you must meet the criteria to unbundle and the status indicator allows you to append the modifier to unbundle.

    Hope this helps!
    Cindy Gallimore, CPC, CENTC

  3. #3
    Location
    Everett, WA
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    Default
    Thanks Cindy, I do understand what you wrote, as in the case of 64405 when it is done the same time as a 20552, as long as the CCI unbundling criteria is MET. However, even using 59 for this type of scenario also has its limitation according to my study. But the examples I submitted at the beginning of this thread fail to meet the criteria for a 59 addition, so again....wouldn't the 51 be used instead? Most likely if I do that..... won't they be denied by UHC and Aetna, for example?

  4. #4
    Location
    Columbia, MO
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    12,570
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    Quote Originally Posted by ollielooya View Post
    Frankly, (and as a new apprentice coder within the past year), I'm still failing to firmly grasp the proper usage of these two modifiers. I've studied and even paid for a modifier course, and have asked my esteemed veterans of many years for their advice, and there is such a variance in answers. Why is this so difficult or is it just me? For example: migraine specialist who has his own office who performs nerve blocks on the same day, such as 64405, 64400 and 64450.
    Wouldn't it be appropriate to use the 51 modifier INSTEAD of the 59 after the 64400 and 64450? Why would one even add the 59 as a modifier of last resort? It does all boil down to what the insurance carriers want it appears despite what one may learn from textbook learning, MCR CCI edits/studies and guidelines . What made all of this "click" for you? ---Suzanne
    Let me see if I can help at all.
    The 51 modifier is used to indicate when two or more procedures were performed in the same session. The purpose is for discounting. Back in the day of manual adjudication of claims they created this modifier to be used to indicated the second and subsequent procedures should be discounted because they were performed at the same session. Now why discount? Because the 100% reimbursement for the first procedure includes the reimbursement for the prep and when subsequent procedures are done at the same time the prep is "carved out" of their reimbursement or discounted.

    The 59 modifier is used to indicated that the second procedure is not a component of the previous procedure, or is not a duplicate entry, rather it is a separate and distinct procedure for consideration. This is why most people call it the unbundle modifier. If the two procedure performed are by definition distinct and separate and no bundling issue exists then there is no need for the 59.
    The short version I give out is... the 59 says to the payer to "pay me I am a distinct procedure".. the 51 says "discount me"
    You may run into payers in this day that no longer put the 51 modifier in their electronic edit system, which is why some find denied claims because it is there. You will need to figure out who they are. Also in you CPT book in the appendix section there is an appendix which lists all procedure codes that are 51 exempt.

    I hope this has bee some help to you.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    That was VERY well put-that helped ME out!

    Amanda, CPC
    Urology coder

  6. #6
    Default
    thank you that helped me out a lot as well

  7. Default
    Thanks, helped me, too.

  8. #8
    Default
    Well said, Deb!! Makes much more sense hearing it put that way. As usual, you are very elequent! Thanks!

  9. Default modifier 51 versus 59
    Here is a procedure for deciding whether to use modifier 51 or 59, and it can be used by the coder who posts the charge, or by the payment poster. The insurance companies sometimes deny these inappropriately, and the person posting the payment has to know when to appeal, and when to write it off.

    http://www.codapedia.com/~article_62_.cfm

    Betsy
    Betsy Nicoletti, M.S., CPC
    www.codapedia.com

  10. #10
    Location
    Everett, WA
    Posts
    886
    Default So, what happens if you don't use modifier 51?
    Playing Devil's advocate here....so, what if there are multiple procedures performed that don't get assigned the 51 modifiers? Will it really effect a denial or decrease the revenue? IF I do not use them, what happens? Honestly, modifier issues have caused the most stress during all my studies. I know some insurance companies don't require or use it, and I've been told it's not necessary for some of the nerve block, and chemodenervation processes our doc performs. ---Suzanne, (who is digging thru the archives deep into the night)
    P.S. Betsy, thank you for your information at the codapedia website. It has been bookmarked and it did help!

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