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59 vs 51 reimbursement

  1. Default 59 vs 51 reimbursement
    Medical Coding Books
    Does anyone, in their experience, know how insurers reimburse for procedures with modifiers 59 and 51. I understand that the mod 51, if correctly placed will decrease reimbursement by 50% per line item. Is that correct and who does your "checking"? Now let's say 2 procedures are done-one through the abdomen and one through the vagina. Not bundled(per edits) so no modifier. Should I expect 100% reimbursement per fee schedule for both codes? If you need an example I have 57288 and 58661. I understand the endoscopic family reimbursement with mod 59(so I think). Thanks for any input.

  2. #2
    Columbia, MO
    Most payers discount the second and subsequent procedure performed in the same session, the reason for this is they consider that part of the reimbursement for each procedure includes a portion for prep and when you do more than one procedure in the same session then the prep does not need to be redone sotherefore it is not paid for twice and the second procedure is discounted to carve out the prep portion. The 51 modifier was/is used to signify that this should occur. With electronic processing most carriers have built an edit to automatically discount the second and subsequent procedure so they no longer want/need the 51 modifier. The 59 modifer is used to indicate a distinc procedure that would otherwise be bundled with a comprehensive procedure. So to answer you question "Should I expect 100% reimbursement per fee schedule for both codes?" no you should not because the payer in all likelihood will discount the one with the lower RVU. If these procedure were performed in two separate sessions then you would need a modifier to stop the automatic discounting. I hope this helps to clarify for you.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Everett, WA
    Soooo, Debra IF the insurance company DOES have the built in edits to discount the additional procedures AND IF it is billed with a modifier 51 anyway, will that discount the revenue even further? Will the payment be affected? Suzanne E. Byrum, CPC

  4. #4
    Columbia, MO
    No they do not discount more due to the presence of the 51. The only thing to watch out for is the issue that some payers (quite a few actually) have deleed the 51 modifier from the electronic edits, and what that means is the presence of the 51 on your claim can have that line item reject for invalid modifier. So you need to find out those payers that still require it and those that do not want it. Also there are some CPT codes that are 51 exempt, this includes all codes with a + sign next to the number and the ones with a 0 with a line thru it, there is an appendix that lists all 51 exempt codes.

    Debra A. Mitchell, MSPH, CPC-H

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