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Resolved CPT Modifiers

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LeslieJ_63438

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I am having trouble deciphering between CPT modifiers 51 and 59. I am getting them confused fairly consistently on practice exam questions. I have read the descriptions in the CPT appendix A what seems like 1,000 times. Is there some sort of “rule of thumb” I could be missing?
 
While modifier 51 and 59 both apply to additional procedures performed on the same date of service as the primary procedure, modifier 51 differs from modifier 59 in that it applies to procedures that may be more commonly expected to be performed during the same session.

Modifier 51 vs 59 - multiple surgeries

Modifier 51 Multiple procedures indicates provider furnished more than one (non-E/M) procedure during the same session. never append modifier 51 to designated add-on codes (any code listed with a “+”) or to modifier 51 exempt codes (identified in CPT by a “circle with a slash” next to the code)
Many payers, including Medicare, use software that negates the need to append modifier 51, under any circumstances. Check with your payer for its guidelines.
For those payers that require modifier 51, append it only to the “lesser valued” procedure codes. Never append modifier 51 to the highest-valued service billed on the claim.
Per CPT® Appendix A (Modifiers), “Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.” Such circumstances may include a documented:
• different session
• different procedure or surgery
• different site or organ system
• separate incision/excision
• separate lesion
CPT® and CMS guidelines agree that modifier 59 should be the “modifier of last resort.” As CPT® Appendix A explains, “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

Applying both 59 and 51 when a code is bundled and is also a subsequent procedure.
Modifier 59 is only used if two codes are bundled, (there is a NCCI edits for the two codes). If there is no edit, a modifier 51 is used. Over-use of modifier 59 is an audit target, so its use should be reserved.
And when modifier 59 is used appropriately, a modifier 51 is redundant and unnecessary. Modifier 59 is always placed on a subsequent, lower valued code negating the need for modifier 51.



Use and Abuse of Modifier 59 - Did You Know CCO #036



LIVE with CCO #017 | Medical Modifiers Made Easy



Review of X EPSU Modifiers | Modifier 59 Alternatives

 
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