Understanding Modifiers 51 and 59

Introduction

In the world of medical billing and coding, accurate reporting is crucial to ensure proper reimbursement and compliance with regulations. One area that often sparks confusion is the use of modifiers when reporting multiple procedures performed by the same surgeon in a single operative session. This article will delve into the specifics of two important modifiers - Modifier 51 and Modifier 59 - and provide insights into how healthcare providers can effectively use them to ensure accurate billing and coding.

Modifiers: Enhancing Precision in Medical Billing

Modifiers play a vital role in the medical billing and coding process, offering a way for healthcare providers to adhere to the guidelines set forth by regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS). They help communicate additional information about a service or procedure performed, ensuring that the claims submitted accurately reflect the complexity and nature of the healthcare services provided.

The Confusion Surrounding Modifier 51 and Modifier 59

Despite the importance of modifiers, there remains a degree of confusion when it comes to distinguishing between two specific modifiers - Modifier 51 (Multiple procedures) and Modifier 59 (Distinct procedural service). Healthcare professionals often wonder which modifier to use when the same surgeon performs multiple procedures in the same operative setting. To clarify, let's explore the correct use of these modifiers.

Understanding Modifier 51

Historically, Modifier 51 was used to indicate multiple procedures. Before 1996, when a surgeon performed multiple procedures, Modifier 51 was appended to the second and subsequent American Medical Association (AMA) Current Procedural Terminology (CPT) codes. However, with the introduction of the National Correct Coding Initiative (NCCI) by CMS in 1996, the process underwent significant changes.

The Role of NCCI and Correct Coding Modifier Indicators (CCMI)

The NCCI aimed to prevent improper unbundling of codes for Medicare Part B services by defining edits based on coding conventions outlined in the AMA CPT codebook, payor policies, coding guidelines, and standard medical practices. This included introducing procedure-to-procedure (PTP) edits, which specify when two codes should not be reported together in the same operative session. Each code pair under PTP edits is assigned a Correct Coding Modifier Indicator (CCMI):

CCMI of "0": Codes that should never be reported together on the same date of service.

CCMI of "1": Codes that can be reported together under defined circumstances, with the use of specific modifiers such as anatomical modifiers or modifiers for staged, repeat, and distinct procedures.

Differentiating Between Modifier 51 and Modifier 59

In cases where no NCCI edit exists for a code pair, Modifier 51 is appended to the additional procedure code(s) with a global period of 000, 010, or 090 when multiple procedures are performed by the same surgeon during the same operative session. However, it's important to note that Modifier 51 should not be appended to add-on codes with a "ZZZ" global assignment.

For instance, if a surgeon performs five procedures during a single operative session, they can expect to be reimbursed 100 percent for the first procedure and 50 percent for the second through fifth procedures, in accordance with Medicare's Multiple Procedure Payment Reduction (MPPR) policy. If more than five different procedures are performed, submitting an operative report becomes necessary for payment of all procedures, which is especially common when billing for trauma care.

Real-World Scenarios: Applying Modifiers in Practice

Let's explore some real-world scenarios to understand how modifiers are correctly applied in different situations.

Scenario 1: Debridement of Wounds

In a scenario involving debridement of wounds, where multiple debridements are performed on different anatomical sites, the use of Modifier 59 is appropriate. This modifier indicates that the procedures are distinct and separate services. For example, debridement codes 11042 and 11044 would be reported as 11044, 11042-59.

Scenario 2: Repair of Incisional Hernia

In the case of repairing a recurrent incisional hernia, where different procedures are performed on the same patient, Modifier 59 is appended to indicate a distinct and separate service. This ensures proper reimbursement and accurate coding. For instance, codes 15734 and 49565 would be reported as 15734, 15734-59, 49565, 49568.

Scenario 3: Small Bowel Laceration and Resection

When dealing with multiple procedures involving different sections of the small bowel, Modifier 59 clarifies that the procedures are distinct and separate. In this example, codes 44602 and 44120 would be reported as 44602, 44120-59.



Scenario 4: Percutaneous Tracheostomy and Gastrostomy

In cases where multiple procedures are performed, but the procedures are not anatomically related, modifiers are used based on payor preference. For example, if a percutaneous tracheostomy and a percutaneous endoscopic gastrostomy are performed, Modifier 59 could be used to indicate that these procedures are distinct. The coding might appear as 31600-59, 43246-51.

Conclusion

Understanding the proper use of modifiers 51 and 59 is essential for accurate medical billing and coding. With the complexities of healthcare procedures and reimbursement policies, healthcare providers must ensure that they apply modifiers correctly to reflect the distinct nature of services performed. Adhering to the guidelines set forth by organizations like CMS and using modifiers appropriately will not only improve reimbursement accuracy but also contribute to compliance with regulations.