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Thread: ERRRR! 51 or 59. Who knows!

  1. #1

    Default ERRRR! 51 or 59. Who knows!

    AAPC: Back to School
    I am completely lost with these two modifiers.
    I can never tell when to use a 51 versus a 59. I have been pouring over articles, and text books, cpt books, and even reading every post I can find in the forums about these two modifiers and I just can't seem to see the difference in these two codes. There descriptions are so similar it's hard to tell the difference. This is a particular stressing issue for me as I recently failed my CGSC exam because just about EVERY question had this issue in it. I am trying to study now to take it again and I am getting very nervous that I still don't get the difference.
    Any tips on how to determine which one to use 51 or 59?????
    Really experiencing icd-9 300.0 right now!

  2. #2
    Join Date
    Apr 2007
    Charleston, WV


    I look at the codes in question and ask "are these codes typically reported together?" If the answer is yes, modifier 51 is appropriate (unless one is an add-on code). If the answer is no, i use modifier 59.

    IMHO modifier 51 should go away. Most payers who still want it reported only use it so that their automated claims systems will reduce the payment of the secondary procedure(s). Since it is often used to reduce the paymnent of the second procedure (usually by 50
    %) always use it on the procedure of lesser value. Basically it says to the payer, "Hey, payer! Juist in case you couldn't tell by the two CPT codes, I did two surgeries during this session so reduce my payment for the second one." For example: Lets say your doc removed a 3.0 cm benign lesion and closed with a layered closure. You would report 11403 for the excision and 12032-51 for the closure.

    Modifier 59 tells the payer, "I know these two codes shouldn't be reported together but in this case it's okay because these two procedures are not related." For example, lets say your doc removed that same lesion as above but with a simple closure. You would still report 11403 but not 12032. But let's say the patient also had a 3.0 cm cut at a different site and the doc closed it with a layered closure. Then we would report 12032-59.

    Hopefully that helps. If not, i hope, at least that it doesn't make it worse.
    J G Stanley, MHA, CPC

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