When billing for multiple procedures on the same day, use this step by step procedure to determine if you should bill for more than one procedure, and if so, if you should use modifier 51 or modifier 59. It is critical to have access to National Correct Coding Initiative ((NCCI) edits in your software program. The NCCI edits are developed by Medicare. They include services that are mutually exclusive, medically unlikely edits, and procedure-to-procedure edits, commonly called bundling edits.
In some groups, the coder performs all of the steps below. The responsibilities indicated here are my opinion, and not law, regulation, or national policy.
Physician Responsibility or Coder Determined from Report for multiple surgical procedures
- List all codes for the procedures performed; in some cases a coder does this.
- Note whether the procedures performed were done via the same compartment, incision, site, organ system, lesion, injury, session and by the same surgeon. If all are the same, note “same.” If any of the above were different, note “different”.
Coder Responsibility
- Check the Relative Value Units for each procedure, and note them next to the code. The code with the highest total RVUs is the primary procedure. The others are secondary procedures. Note the primary procedure.
- Check the CCI edits. If the secondary procedures are component codes of the primary procedures, and the procedure was the same (as indicated above), bill only the primary procedure. Use the current version of the NCCI edits.
- If the secondary procedures are not component codes of the primary procedure, and the procedure was the same (as defined above), bill the primary procedure with no modifier, and the secondary procedures with -51 modifier. This indicates that multiple procedures were performed that fall into the category of “same” as indicated above. (Not all payers required/want –51 modifier on a claim.)
- If the secondary procedures are component codes of the primary procedure, but the procedure meets the different criteria above (different session, compartment, lesion, injury, etc.) bill the primary procedure with no modifier and bill the secondary procedures with a -59 modifier.
Payment Implications
Payers will not pay for bundled procedures separately if performed through the same incision, etc. Modifier -59 tells the payer that even though this is a bundled procedure, it is separately payable (within the multiple procedure reductions) because it was a different session, incision, compartment etc. It tells the payer: this is not a duplicate or repetitive submission. It is a component code of the primary procedure, but pay it because it is a different session, site, compartment, incision, etc.
Medicare tells us that modifier 59 is the modifier of “last resort.”
Using modifier 51 allows you to be paid for multiple procedures in the same day that are not bundled together. Medicare payers do not require modifier 51 on the claim form, Commercial payer policy varies.
As of this writing, CMS has not clarified the use of the –X {EPSU} modifiers.
Don’t use these until CMS clarifies their use, unless you have a payer or MAC that requires them.