Monday, April 11, 2011

Modifier 51 or 59? Choose Carefully

The physician controlled a patient's hemorrhage (30901) and removed a benign lesion from patient's temple (17110) during the same encounter. How should you go about this situation – report modifier 51 or 59?

As per coding rules, you should append modifier 51 (Multiple procedures) only when the doctor completes multiple procedures during the same encounter, and to add modifier 59 (Distinct procedural service) only when the two procedures you want to submit are not usually submitted together but are proper under the circumstances. Often modifier 59 is used to code pairs that have an active bundling edit through the correct coding initiative (CCI). Present CCI edits don't bundle codes 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) and 17110 (Destruction [example laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions).

You will most likely find different opinions on whether to add modifier 51 or 59. Some medical coders go for modifier 51 since most payers will process the encounter as a multiple surgical reduction irrespective of whether you include the modifier or not. Other medical coders recommend modifier 59 since reporting 51 could set you up for one of three undesirable (or at least aggravating outcomes); the payer does not bring down the payment correctly; the payer denies the entire claim; or the payer requests additional documentation prior to considering payment. Of the two modifiers, most probably modifier 51 is most appropriate in this example.

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Tip you can follow: Whichever modifier you choose, add it to the lowest relative value units – (RVUs) -- in this instance, code 30901 with 2.82 relative value units.

What's more, double-check the code you are submitting for the lesion removal. As noted, the code you indicated (17110) is for destruction of a lesion by one of various methods. If the doctor removed the lesion through excision, you'll need to use a code from the series of codes for excision of benign skin lesions, 11400-11446.