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cpt code 27096 and the use of modifier 51

  1. Default cpt code 27096 and the use of modifier 51
    Medical Coding Books
    Recently one of our coders was auditing a report for proper coding and coded 27096 x2 and added modifier 51 to the 2nd 27096. There have been a couple denials on these certain ones. I was wondering if you could code 27096-51. I havent seen it done until this coder and now we have been receiving denials

    i didnt mean that she actually coded 27096 x2 on a claim form by this i was meaning 27096 twice.

    example 27096
    27096-51
    Last edited by jessieindiego; 09-08-2008 at 02:55 PM.

  2. #2
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    I'd code it as:
    27096
    27096.51
    (not 27096x2)
    per the RVU schedule you should modifier the second one with a .51 modifier
    {that's my opinion on the posted matter}

    actually - I was just reviewing my answer - and 27096 has a "1" in the bilateral procedure area - so if it's a bilateral procedure you'd have to use a:
    27096.50

    but if it's multiple injections, same side - it would be the:
    27096
    27096.51

    (also, RT/LT wouldn't hurt either if it's one side or the other)
    Last edited by dmaec; 09-08-2008 at 03:26 PM.
    Donna, CPC, CPC-H

  3. #3
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    because you are using the same CPT twice, I would code as follows
    27096-rt
    27096-59-lt

    You can use the 50 modifier but I personally tend to stay away from them as there are too many carrier descrepancies to keep up with.

    Of course if you are billing for a physician, you may also need to add the 51 modifier on the second line.

    I'm assuming that this isnt a Medicare patient (if so, then you can not use the 27096, you would use the G0260 instead)

    Mary

  4. #4
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    Quote Originally Posted by jessieindiego View Post
    Recently one of our coders was auditing a report for proper coding and coded 27096 x2 and added modifier 51 to the 2nd 27096. There have been a couple denials on these certain ones. I was wondering if you could code 27096-51. I havent seen it done until this coder and now we have been receiving denials

    i didnt mean that she actually coded 27096 x2 on a claim form by this i was meaning 27096 twice.

    example 27096
    27096-51

    jessieindiego -
    to answer your "original" question - the answer is "yes", you can use the .51 on this code. It's actually the correct modifier to use, unless you're doing it bilaterally. Some facilities do use the .59, and shy away from the .50 biliateral, but that doesn't mean it's correct to do so. If things do get denied, and they are coded correctly - you should appeal, (in my opinion). We use the .50 modifier when appropriate, we use the .59 at times for other instances and we use the .51 accordingly as well. But we do not attach the modifiers to codes for the sake of pushing the claim through. We have denials, and we have appeals, and when the claim is coded correctly, we appeal. Keep in mind also, that some carriers do like to see charges billed "their" way, and there are ALWAYS exceptions to the rules!
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  5. #5
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    IF you are putting these codes on seperate lines, then IT IS appropriate to add the 59 modifier as well as the 51 if required. It is NOT to "push the claim through" as Donna has insinuated, it is howeverto identify to the carrier that this is a separate site of injection and is MOST APPROPRIATE. You will need more than a 51 to get the claim paid (if billed on seperate lines), as generally the second line will deny as a duplicate of line one.

    Per the training that I have received over the years, there is no right or wrong to using the RT/LT versus the 50 modifier, it is generally a carrier descretion. (There is actual documentation from Medicare for pain procedures..which this could be considered, that states to bill them on seperate lines with the 59).

    Donna do you have documentation that you can share from a credible source to support that we must use the the 50 modifier rather than RT/LT?

    Thanks
    Mary

  6. #6
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    Mary -
    I consider the RVU schedule a very credible site - and per it - and the little number "1" in the bilateral surgery rule box - it means, "bilteral surgery rules apply - use modifier .50 if bilateral. If it had a "0, 2, 3, or 9", I would use the RT/LT and the .51). Actually, I did state earlier also, that RT/LT wouldn't hurt. (if it was not done bilaterally)

    as I mentioned in another forum, we tend to follow Medicare guidelines for most of our carriers - it hasn't lead us wrong yet - as most of the carriers also go by Medicare guidelines. So we tend to follow the RVU schedule, the CCI Edits, etc...

    and again - ALWAYS exceptions to the rules - and we all have our opinions -it's coding

    {that's still my opinion on the posted matter}
    Donna, CPC, CPC-H

  7. #7
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    Jessieindiego,

    I believe that the reason for your denial is the lack of the 59 modifier on the second line item. Double check your EOB to see if its denying as a duplicate. If so, then thats your culprit. Check with your carrier to see what their guidelines are as well.

    After reading Donna's statement above, I did go and read the Medicare National Correct Coding Policy, Chapter 1 which addresses modifiers, prior to making this response, and it does not address the use of the 50 modifier.

    Since I have been through a number of audits in the past 20 years, I've never been dinged for the use of the RT/LT versus the 50, therefore I am comfortable with my response above indicating how I would code it if it is truly a bilateral procedure.

    Thanks
    Mary

  8. #8
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    Modifier .50 is a statistical modifier that affects pricing. the LT/RT mods are statistical informational modifiers. There is a ranking for "how to" attach modifiers, pricing modifiers FIRST - statistical modifers that affect pricing SECOND. The statistical information modifiers fall SECOND also, only if there are not other modifiers that affect payment.
    This info can be found in the March 2008 CMS Modifier Reference

    Other info I use from "medicare" -
    Hints for using the modifier 50 - USE to report a procedure done BILATERALLY in same session - DO NO use if code indicates muliple occurences - DO NOT use if code indicates the procedure applies to different body parts - DO NOT use if code description included "bilateral" or "unilateral"

    Hints for using the modifiers LT/RT - use to identify procedures performed on the right/left side of a paired organ or central lateral anatomic site body. - USE when the procedure is performed on only one side to identify the side operated on. - DO NOT use if code indicates the procedure applies to different body sites or anatomic structures. - DO NO use RT/LT if a more specific modifier is available - DO NOT use RT and LT when modifier 50 is appropriate.
    (again, Medicare website)

    in this case "if" it was done bilaterally - given it's "1" rating on the RVU schedule - I would indeed use the .50 and not RT/LT - (if it was done bilaterally)

    That being said:

    Mary, I understand how/why you'd do it that way by what you've posted. I'm just saying, I do it differently. My response to the question is based on my years of coding exerience and audits galore also. I too, am confident in my opinion, it's why I gave it. What I state is what works for me, my facility.

    Really - no need for "puffing out the chest" ..

    This is a forum for discussion, we don't all have to agree - I've learned much from others and often post for opinions on things I'm doing. I get wonderful responses as to why something different might work or be a better way. When I have issues I research other coders ways of doing things, if it makes sense and it's correct coding - I have no problem changing the ways we do it. If the way we do things "now" doesn't seem to have any issues, change wouldn't be needed. I'm simply stating my opinion (note my disclaimer at the end of each post) it's "my opinion", it's NOT gospel. It what works for me, my facility and it too is based on years of experience.

    you and I obviously disagree on this issue - I've no problem with that ..
    jessieindiego can take the information we all provide and make her own decision.(in fact, it would be very wise of her to do her own research, she has a great starting point with the opinions posted here!)

    {again, that's still my opinion on the posted matter}
    Donna, CPC, CPC-H

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