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Pain Mgmt--Modifier 51 or 59

  1. #1
    Jacksonville River City
    Question Pain Mgmt--Modifier 51 or 59
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    Which way would be the correct way to bill the following procedures as far as modifiers are concerned? There is controversy in our office as to which is correct.

    64490 (723.1 & 729.2)
    64450-51 (729.2)


    64490 (723.1 & 729.2)
    64450-59 (729.2)

  2. #2
    No bundling issue exists with codes: 64490 and 64450. You could bill with the 51 modifier. Typically the rationale for using the 59, is when according to the NCCI guidelines, the column two code is considered bundled. You add the 59 to state that it meets the criteria for separate payment after reviewing the NCCI policy manual. There are other circumstances with certain commercial carriers that would need the 59 instead of the 51 on certain code combinations.

    "For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes."

    The CPT Manual defines modifier 59 as follows:
    "Modifier 59: Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter,different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

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