Thursday, October 21, 2010

multiple surgeries on the same date of service - Modifier 51

Modifier 51

When billing multiple surgeries on the same date of service and same operative session, the primary procedure should be billed without a modifier 51 and subsequent surgical procedures should be billed with a modifier 51 appended. The exception is “Add-On” codes which do not  require a modifier 51.

Effective April 1, 2007, Medicaid adopted the CPT Policy for Modifier 51 Exempt procedure codes. Therefore, all Modifier 51 Exempt procedures are NOT subject to rule of 50 percent reduction. The other exception to the 50 percent reduction is “Add-On” codes.

Multiple Surgical Procedures

When more than one surgical procedure is submitted for a recipient on the same date of service, the claim is always reviewed by the Medical Review Unit, regardless of the method or timing of claim submittal.

When submitting multiple surgical procedures within the same anesthesia session, providers should bill the major procedure with no modifier and append a -51 modifier on all other procedures, unless the code billed is listed in Procedure  as exempt from modifier -51.

* *  If a -51 modifier is appended to a “modifier -51 exempt” code, the claim will be denied.

* *  If a -51 modifier is required and is not appended, the claim will be denied.

* *  Louisiana Medicaid no longer accepts a -51 modifier on add-on codes. Incorrectly paid add-on codes are subject to recoupment.

If the provider has not designated a primary procedure by appending a -51 modifier to the secondary procedure(s), the claim will be processed as follows:

* *  The lowest numerical Procedure  code will be paid as the primary procedure by the system.

* *  Subsequent codes will pend to Medical Review.

* *  The primary procedure will be paid at 100% of either the Medicaid allowable fee or the billed charge, whichever is lower. All other procedures will be paid at 50% of the Medicaid allowable fee, or 50% of the billed charge, whichever is less.

Multiple Surgical Modifiers

Multiple modifiers may be appended to a procedure code when appropriate. Billing multiple surgical procedures and bilateral procedures during the same surgical session should follow Medicaid policy for each type of modifier.

Bilateral secondary procedures should be billed with modifiers 50/51 and if appropriate, will be reimbursed at 75% of the Medicaid allowable fee or 75% of the billed charges, whichever is lowest.

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