When multiple procedures, other than Evaluation and Management (E/M), Physical Medicine and Rehabilitation services or provisions of supplies (e.g., vaccines) are performed at the same session by the same individual, the primary procedure or service may be reported as listed. Multiple procedure rules apply to the secondary procedure or service.
Instructions
Do not append modifier 51 to the additional procedure code. The Medicare claim processing system has a hard coded logic to append it to the correct procedure code. CPT also lists codes that are modifier 51 exempt.
Correct Use
Below are situations when multiple procedure rules apply.
Append when same physician performs more than one surgical service at same time (Indicator 2)
Append when technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction (MPPR) rule apply (Indicator 4)
Append when multiple surgical procedures are done on same day but billed on two separate claims
Incorrect Use
Do not append modifier 51 to additional procedure code
Do not append to add-on codes (See Appendix D in the CPT manual)
Do not append to all lines of service
Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on same day to same patient
Modifier 51 Fact Sheet
In Medical billing Modifier usage will be crucial.
Medicare does not recommend reporting Modifier 51 on your claim; the processing system has hard-coded logic to append the modifier to the correct procedure code.
Definition:
• Multiple surgeries performed on the same day, during the same surgical session.
• Diagnostic Imaging Services Subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider
Appropriate System Usage:
• When both diagnostic procedures have an indicator of “4” in the MPFSDB “Mult Surg” column and both diagnostic procedures have the same “Diagnostic Imaging Family Indicator” in the MPFSDB
• When the same physician performs more than one surgical service at the same session.
• When the MPFSDB indicates a “01-11” in the “Diagnostic Imaging Family Indicator” column.
• When both surgical procedure codes have an indicator of “2” in the MPFSDB “Mult Surg” column.
• Append modifier 51 to the surgical procedure code with the lower physician fee schedule amount.
• Append modifier 51 to the diagnostic imaging procedure with the lower technical component fee schedule amount.
Inappropriate System Usage:
• Do not use with designated add-on-codes.
• Do not report on all lines of service.
I noticed a ‘multiple procedure’ modifier on my remittance advice but I did not submit it. The service was allowed, but should I have included this modifier on my claim?
Answer:
No. CPT modifier 51 is a system-generated modifier. It is used to ensure multiple surgeries submitted for a patient with the same date of service are reimbursed correctly. We ask that providers not use this modifier.
Additional Information:
• Medicare pays for multiple surgeries by ranking from the highest physician fee schedule amount to the lowest physician fee schedule amount.
o 100% of the highest physician fee schedule amount
o 50% of the physician fee schedule amount for each of the other codes
• Medicare will forward the claim information showing Modifier 51 to the secondary insurance.
• Multiple surgery pricing logic also applies to assistant at surgery services.
• Multiple surgery pricing logic applies to bilateral services (modifier 50) performed on the same day with other procedures.
Billing and payment Guidelines.
Modifier 51 is considered valid for procedures with a multiple procedure indicator of 2, 3, 4, 5, 6, or 7.
The CMS Physician Fee Schedule indicates that modifier 51 is not eligible to be used with the CMT codes (98940 – 98943). Moda Health will deny 98940 – 98943 for invalid modifier combination when billed with modifier 51.
The -51 modifier itself does not affect payment. Multiple surgical payment is based on whether the surgical procedure may be subject to a multiple surgery. Then the reduction would be based on the allowed amount. The lowest valued procedure(s) will have the multiple surgical reduction applied. When covered, payment is made at 50% of the allowed amount for all allowable secondary procedures. Multiple surgery pricing logic also applies to bilateral procedures
NOTE: It is important that modifier 51 be added to the second and subsequent codes based on RVU order; not on the primary procedure based on what was done to address the patient’s illness. Do not apply modifier 51 in the following situations:
• Do not use modifier 51 on any CPT codes designated Modifier 51 Exempt
• Do not use modifier 51 on designated Add-on Codes
• Do not use modifier 51 on services which require modifier 50 (bilateral procedures) as the multiple procedure discount is already included in reimbursement for bilateral procedures.
Modifier 51 Examples
• Colonoscopy (45378) performed at the same session as upper endoscopy (43200). Use modifier 51 on the upper endoscopy (43200) because the RVU’s are lower than the colonoscopy (45378). 45378, 43200-51.
• Excision, malignant lesion, trunk, 0.5cm or less (11600) performed at the same session with intermediate repair (layer closure) of wounds of trunk, 5.0 cm
(12032). Use modifier 51 on the excision (11600) because RVU’s are lower than the repair. 12032, 11600-51.
Modifier 51 should be applied to all other codes when multiple non-E/M services are provided at the same session. Modifier 51 can be used with other modifiers, when
appropriate, except modifier 50.
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.
Do not append modifier 51 to a procedure to indicate that additional procedures were performed by a different provider in the same session.
Do not use modifier 51 to report an evaluation and management (E/M) service and a procedure performed on the same day.
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures (such as multiple procedure fee reductions) account for the overlap of the preprocedure and post-procedure work.
Multiple Procedure (Modifier 51)
*Multiple procedures other than Evaluation & Management performed at same session, by same physician on the same patient on the same day
*Do not use with add-on codes
*Not required for billing
*Reduction determined by the MPFS approved amount
*M/S pricing indicators effect surgical procedures, endoscopy rules, technical components, therapy services, cardiovascular and ophthalmology services
Category Indicator Indicator Description
0
No payment adjustment rules for multiple procedures apply. If procedure is reported on same day as another procedure, base payment on lower of a) the actual charge or b) the fee schedule amount for the procedure.
1
Standard payment adjustment rules in effect before January 1, 1996 for multiple procedures apply. In the 1996 MPFSDB, this indicator only applies to codes with procedure status of “D”. If a procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report).
2
Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50%, and by report).
3
Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).
Medicare payment indicator for Multiple Procedure (Modifier 51)
Indicator indicates which payment adjustment rule for multiple procedures applies to the service. 0 = No payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure.
1 = Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply. In the 1996 MPFSDB, this indicator only applies to codes with procedure status of “D.” If a procedure is reported on the same day as another procedure with an indicator of 1,2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 25 percent, 25 percent, 25 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
2 = Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on thesame day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the endoscopic base code field.
Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure).
If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.
4 = Subject to MPPR reduction.
9 = Concept does not apply
When multiple procedures are performed during the same operative session, report the major procedure as listed. In order to ensure appropriate processing and correct payment, providers billing multiple procedures must bill the procedure with the highest allowed amount on the first line of the claim.
For pricing information, please refer to the Medicaid Fee Schedules located in the Rates & Fee Schedules section of the Department’s web site.
The provider should bill for the most costly or most complex procedure on the first line of the claim. The secondary, additional, or lesser procedure(s) may be listed and identified by adding the modifier 51 to the secondary procedure code(s). This modifier should not be appended to designated “addon” codes.
Single surgical field or single surgical incision – Multiple procedures performed by one or two surgeons, regardless of how many organ systems are involved, will be reimbursed at 100 percent for the procedure commanding the greatest value and 50 percent for the second or subsequent procedures.
Two surgical fields or two surgical incisions – Multiple procedures performed by one surgeon, involving separate organ systems or different anatomical locations, will be reimbursed at 100 percent for the procedure commanding the greatest value and 50 percent for the second or subsequent procedures. Multiple procedures performed by two surgeons, involving separate organ systems or different anatomical locations, will be reimbursed at 100 percent for the procedure commanding the greatest value and 100 percent for the second procedure.
Foot surgery – single surgical field/incision or two surgical fields/incisions on the same foot will be reimbursed at 100 percent for the procedure commanding the greatest value, 50 percent for the second procedure, and 25 percent for each subsequent procedure. Bilateral procedures (left and right foot), or two surgical procedures performed on both feet (one procedure on the left foot and one procedure on the right foot) will be reimbursed at 100 percent for the procedure commanding the greatest valued and 80 percent for the second procedure.
Applicable Providers
• Physicians, all specialties
• Multi-specialty Clinics
• Optometrists
• Podiatrists
• Nurse Practitioners
• CRNA
• Nurse Midwives
• Ambulatory Surgical Centers
General Information
Modifier 51 indicates several procedures were performed on the same day or at the same operative session, by the same provider. Modifier 51 identifies surgical procedures performed in combination, whether through the same or another incision or involving the same or different anatomy. Multiple related surgical procedures or a combination of medical and surgical procedures performed at the same session must be designated with modifier 51. Policy Medicaid will not determine the major procedure for the provider. It is the provider’s responsibility to correctly identify the primary and secondary procedures in order to be reimbursed appropriately. The primary procedure billed on the first detail of the claim without modifier 51 will be reimbursed at 100% of the allowed amount, and subsequent procedures billed with modifier 51 will be reimbursed at 50% of the allowed amount. Medicaid will not adjust claims for additional payment if the provider neglects to report the major surgery on the first detail. The assistant surgeon must also bill the primary procedure without modifier 51 and subsequent procedures with modifier 51. If a patient returns to the operating room for a subsequent procedure on the same day by the same provider, modifier 51 must be appended.
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