Fam Pract Manag. 2003 Nov-Dec;10(10):19-20.
Modifiers -51 & -59
What is the practical difference between modifiers -51, “Multiple Procedures,” and -59, “Distinct Procedural Service?”
Modifier -51 indicates that you did more than one procedure at the same session. For example, if you excise a benign skin lesion with an excised diameter over 4.0 cm from a patient’s chest and close the defect using a layered closure, you would submit code 11406 (“Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter over 4.0 cm”) and 12032–51 (“Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm”). Since payers, such as Medicare, typically reduce the fee for the code with modifier -51 attached by about 50 percent, you should attach it to the lesser-valued service so that you are paid in full for the more expensive procedure. However, be sure to bill the full fee for each procedure and let the payer make the reduction consistent with its own payment policy.
Modifier -59 indicates that two services not normally reported separately are appropriately reported separately under the circumstances. For example, if you see an accident victim in the emergency room and the patient requires fracture care on the right arm and some strapping on the left arm, you may need to attach modifier -59 to the strapping code to indicate that it was separate from and should not be bundled with the fracture care, which includes the initial cast, strap or splint. Modifier -59 should be attached to the lesser valued of the two services or to the code, regardless of value, that would otherwise be denied or is a component of another, more comprehensive code. This modifier is usually considered a last resort, since its descriptor says that it should only be used “if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances.”
Occasionally, you can use both modifiers at the same time. Using the earlier example, if you perform a skin biopsy of another lesion on the patient’s chest during the same visit, you would submit 11100 (“Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion”) in addition to the other codes and append modifier -51 and modifier -59 to it. Modifier -51 would be attached because the biopsy is the lesser-valued procedure done at the same session, and modifier -59 would be attached to indicate that the biopsy, which is normally bundled with excision of the same lesion, was done on a separate lesion from the one that was excised.
Hospital consultation codes
I was told that I shouldn’t be using consultation codes when asked to consult on established patients in the hospital. Is this correct?
It depends on the situation. For example, if a surgeon admits one of your established patients for hip surgery and, subsequent to the surgery, asks you for your opinion and advice regarding evaluation and/or management of the hypertension the patient is having in the hospital, you may code that service as a consultation, provided that you document the request and any services ordered or performed and that you communicate a written report to the surgeon. For this consultation, you would submit an initial inpatient consultation code (99251–99255). Follow-up inpatient consultation codes (99261–99263) could be submitted for any subsequent consultations performed during the patient’s inpatient stay under any of the following circumstances:
When you need an additional visit to complete the initial consultation;
When the attending physician requests additional evaluation of the same problem;
When the attending physician requests evaluation of a new problem (there can only be one initial in patient consultation per patient by the same physician per hospitalization).
Consultation codes may also be appropriate for some postoperative evaluations. The Medicare Carriers Manual states that “a physician who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for [E/M] services furnished during the postoperative period following surgery as long as all of the criteria for the use of the consultation codes are met and that same physician has not already performed a pre-operative consultation” (emphasis added). Thus, when consultations are performed on Medicare patients in the hospital before and after surgery, the pre-operative consultation can be coded as described above and the postoperative consultation can be coded with the appropriate subsequent hospital care code (99231–99233). Subsequent hospital care codes should also be used instead of consultation codes if another physician asks you to manage part of a patient’s inpatient care rather than simply to provide your advice or if you assume responsibility for management of all or part of a patient’s inpatient care after you render your consultation.
What diagnosis code should I submit for anaphylactic shock due to exercise?
Try submitting 995.0, “Other anaphylactic shock,” which includes anaphylaxis not otherwise specified.
In the July/August issue, “CPT code for semen analysis” [page 26] indicated that CPT code 89321 should be used for semen analysis post-vasectomy. This is true as long as the vasectomy and semen analysis were not performed by the same entity (e.g., if a family practice office lab does a semen analysis for a patient who received a vasectomy from a urologist across town). When the two services are performed by the same entity, the more appropriate code to use is 55250, “Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s).”
Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to Family Practice Management. These questions and answers were reviewed by members of the FPM Coding & Documentation Review Panel, which includes: Robert H. Bosl, MD, FAAFP; Marie Felger, CPC; Thomas A. Felger, MD, DABFP, CMCM; David Filipi, MD, MBA, and the Coding and Compliance Department of Physicians Clinic; Lynn Handy, CPC, LPN; Emily Hill, PA-C; Joy Newby, LPN, CPC; P. Lynn Sallings, CPC; and Susan Welsh, CPC.
Conflicts of interest: none reported.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most detailed and up-to-date information.
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Copyright © 2003 by the American Academy of Family Physicians.
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