Denise M. Nash, MD, CCS, CIM
Vice President of Compliance and Education, MiraMed Global Services
In part 1 of this article (our May, 2014 issue) we discussed modifier utilization for procedures increased, reduced or discontinued. Below are several modifiers that might apply when billing for multiple procedures performed on the same day (50, 51 and 59)or modifier 25, if an E&M was done in conjunction with a procedure.
Modifier 50-Bilateral Services are procedures performed on both sides of the body during the same operative session or on the same day.
- The purpose of this modifieer is to report bilateral procedures performed at the same operative session by the same physician.
- Modifier 50 must only be applied to services and/or procedures performed on:
- identical anatomic sites,
- aspects, or
- Append modifier 50 on bilateral organs such as the kidneys, ureters and hands.
- Append modifier 50 when code description doesn't already state that the proedure is bilateral.
- Do not append modifier 50 when the description inclused the phrase "one or both."
- Do not append modifier 50 to procedures on the skin because the skin is one organ.
- This modifier should not be used on procedures which have a bilateral surgical indicator equal to 0, 2, 3 and 9 on the Physician Fee Schedule Relative Value file. Any procedure billed to Medicare/Medicaid that has been assigned to one of these indicators will be denied unless CMS has instructed differently through provider bulletins and/or manuals.
- This modifier should only be used on procedures which have a bilateral surgical indicator equal to 1 on the Medicare Physician Fee Schedule Relative Value file. Any procedue billed to Medicare/Medicaid that has been assigned this indicator will be processed and reimbured as normal.
Adapted from: http://www.cms.gov/apps/physician-fee-schedule/
- Modifier 50 is a processing/reimbursement modifier, and the rate is 150% of the base code for Medicare/Medicaid.
- Please check with carrier on how to bill bilateral.
- Modifier 50 cannot be used when the code description indicates unilateral or bilateral.
Example: The surgeon performed a carpal tunnel on the right and left during the same operative session 64721‐50, neuroplasty and/or transposition; median nerve at carpal tunnel (includes external neurolysis).
- Some carriers prefer a “two code” listing
64721, 64721‐50 or 64721‐RT, 64721‐LT.
Modifier 51-This modifier is used to identify the secondary procedure or when multiple procedures are performed on the same date or during the same operative session by the same physician.
- 51 modifier is only appended to secondary procedure codes when multiple procedures are performed on the same date.
- When multiple procedures, other than evaluation and management services, are performed on the same day or at the same session by the same provider, the major primary procedure or service may be reported as listed. The secondary additional or lesser procedure(s) or service(s) may be identified by appending the modifier 51 to the secondary additional procedure or service code(s). Multiple surgeries must be submitted by appending the modifier 51 to the codes with lower allowed amounts.
- This modifier may be used to report multiple medical procedures performed at the same session, as well as a combination of medical and surgical procedures, or several surgical procedures performed at the same operative session.
- This modifier should not be used on procedures which have a Multiple Procedure indicator equal to 0 and 9 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid that has been assigned one of these indicators will be denied unless Medicaid has instructed differently through bulletins and/or provider manuals.
- This modifier should only be used on procedures which have a Multiple Procedure indicator equal to 1, 2, 3 and 4 on the Medicare Physician Fee Schedule Relative Value file. Any procedure billed to Medicaid that has been assigned any of these indicators will continue to be processed as normal.
*This modifier cannot be submitted with designated add‐on codes (refer to the CPT® codebook for a list of add‐on codes). Also, any code with a Global Surgery indicator equal to ZZZ on the Medicare Physician Fee Schedule Relative Value file is considered an add-on code.
Modifier 59-The purpose of this modifier is to identify procedures or services that are not usually reported together but appropriate under the circumstances.
- Under certain conditions the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.
- A different session or patient encounter
- Different procedure or surgery
- Different site or organ system
- Separate incision/excision
- Separate lesion
- Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician
*Modifier 59 cannot be appended to an E/M service.
- Documentation must be specific to the distinct procedure or service and clearly identified in the medical record.
- Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion or separate injury, etc.
Example: Excision of a benign lesion of the chest and Irrigation and Drainage of an abscess on the neck.
- Code 11400-Excision benign lesion, except skin tag, trunk, arm, or legs; lesion diameter 0.5 cm or less.
- Code 10060‐59-I & D of abscess.
Modifier 25-Significant, separately‐identifiable evaluation and management service by the same physician on the same day of the procedure or other service.
- The purpose of this modifier is to indicate that a significant, separately identifiable E/M service was performed by the same physician on the same day of a procedure due to the patient's condition requiring it to be performed.
- The E/M service has to be above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. See the Surgery Guidelines in the most recent issue of the CPT manual for the definition of "global surgical package."
- Different diagnoses are not required for reporting E/M service on the same date.
- This modifier must not be used to report an E/M service that resulted in a decision to perform surgery (the modifier utilized for decision for surgery on same day would be modifier 57).
- E/M service must meet key components: history, examination, medical decision making.
- Modifier 25 must only be appended to the E/M codes.
Modifier 25 should be used only when a significant, separately‐Identifiable E/M visit is rendered on the same day as a minor surgical procedure. Payment for preoperative and postoperative visits is included in the payment for the procedure. For minor procedures, where the decision to perform the minor procedure is typically made immediately before the service (e.g., whether sutures are needed to close a wound, whether to remove a mole or wart, etc.), the E/M visit is considered to be a routine preoperative service and should not be billed in addition to the minor procedure. The policy applies only to minor surgeries and endoscopies for which a global period of 0‐10 day applies.
Documentation must support the chosen E/M service level code and be referenced by a diagnosis code, confirming that the E/M service billed was above and beyond the ELM services included in the procedure and over and above the services normally included in the pre-op and post-op for the procedure.
Normal pre-operative work includes:
- Assessing the site and condition of the problem area
- Explaining the procedure
- obtaining formal consent.
*Source: Modifiers: It’s All in the Detail by Katherine Abel, CPC, CPC‐I, CMRS, American Academy of Professional Coders
Example: A Medicare patient presents for follow up for hypertension and diabetes. The patient also complains of left knee pain. The physician evaluates the patient’s hypertension, and determines the blood pressure is higher than it should be and adjusts medications. The patient’s blood sugar is doing well and the diabetes is well controlled with the current insulin regimen. The physician evaluates the knee and determines the patient should undergo Arthroscopy. The patient is given a steroid injection and scheduled for the procedure to the done the following month.
In this example it would be appropriate to bill the Evaluation and Management Service as well as 20610 Arthrocentesis, aspiration and/or njection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa).
(To be continued in the next issue.)