Friday, April 30, 2010

CPT modifiers 51 & 53

Surgical - 53 Modifier

53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the
discontinued procedure.

Use modifier 53 (discontinued procedure) to report a failed or terminated colonoscopy, or a failed or discontinued procedure. Documentation describing the circumstances requiring the discontinuation of a procedure should be provided with the claim submission. If this information is NOT included, your claim may be denied.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC
hospital outpatient use).

Surgical - 51 Modifier

51 Multiple Procedures: When multiple procedures, other than evaluation and management services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s).

Note: This modifier should not be appended to designated “add-on” codes (e.g., 22612, 22614).


URMC Compliance Office Guidance for Use of Modifier 51 Multiple Procedures Example when 51 Modifier is not used

• Patient with bilateral simple mastectomies (19303, 19303-50) would not be billed with modifier 51.

• Physician A performs partial colectomy with anastomosis (44140) and Physician B performs ureteropyelostomy (50740) at the same session would not be billed with modifier 51 as the services were performed by different providers


Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

 The standard Medicare system handles multiple surgery logic automatically without the presence of a 51 modifier. The use of the 51 modifier in an incorrect situation will cause the related claim line to either reject or deny. Please note the 51 modifier is not required to report multiple surgeries. The use of modifier 51 for billing purposes by providers is discouraged and can adversely affect payment if used incorrectly. However, the correct use of modifier 51 will not have an adverse affect on your claim.

Can you explain the 51 modifier rule when multiple procedures are done thoughout the day both in and out of OR by the same Physician? Example Trauma with multiple procedures in ED, OR, and bedside thoughout the same day.

The primary (highest RVU) procedure rendered during the overall DOS is listed first with no modifier. The other surgical codes will have Modifier 51 appended unless an exception applies (add-on, 51 exempt).


Modifier 51 is used By the primary surgeon, assistant surgeon and ambulatory surgical facility to indicate that more than one surgery was performed by the same physician on the same patient on the same date of service


Billing

• If the procedure includes multiple eyelids, each eyelid must be billed on a separate detail with the appropriate modifier. Subsequent areas must be billed with modifier 51 denoting multiple surgery if appropriate.

• If the description of the base procedure code already describes a particular eyelid, use the appropriate modifier that describes the same eyelid. For example, procedure code 15820 is described as “Blepharoplasty, lower lid.” Only modifiers E2 and E4 are appropriate with this procedure code.

• If the procedure includes multiple toes, each digit must be billed on a separate detail with the
appropriate modifier identifying that toe. Subsequent digits must be billed with modifier 51 denoting multiple surgery if appropriate. Add-on codes are those whose CPT description includes phrases such as “each additional” or “list separately in addition to primary procedure.” They do not require modifier 51, and are not paid unless the primary procedure is billed and paid. Please refer to modifier 51 for more information on add-on codes.

• If the description of the base procedure code already describes a specific digit, use the  correct modifier that describes the same digit. For example, code 28505 is defined as open treatment of fracture great toe. This code must be billed with TA or T5. 

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