Modifier 51 vs Modifier 59

As per AMA, the defination of Modifier 51

Modifier 51 (Multiple Procedures): When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, 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).

Note: This modifier should not be appended to designated “add-on” codes (see Appendix D).

Difference between Modifier 51 and Modifier 59

Can we use 51 modifier with E&M Codes?

No, we can use 51 along with E&M codes

Can we use 51 and 59 together for the same CPT?

No, an additional procedures can be either distinct or multiple .So we cant use both modifier together.

How it will affect if i dont use 51 modifier?

As for most of the payor, the primary procedure is paid 100% and multiple procedure will be 50%.So, you claim will not be denied.

For which CPT we have to use 51, if there are 3 different procedure performed ?

For multiple procedure performed at the same time, the procedure with higher Value will be consider as primary procedure and the rest other procedure will be multiple procedure or additional procedure.

If physician is doing procedure through different incision and performing multiple procedure , should we use 51 modifier?

Yes, if the procedure is payable as per coding guideline, we can give 51 ,even it is performed through separate or same incision.

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As per AMA, the defination of Modifier 59

59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Modifier 59 is used to show that a procedure or service is separate and distinct from another procedure done on the same day.

Sometimes two services are normally not billed together, but in special situations, they should be—and Modifier 59 helps you communicate that to the payer.

When should you use 59 Modifier

Use Modifier 59 only when documentation clearly shows the service was separate by:

• Different session (performed at a different time)

• Different procedure or surgery

• Different site or organ system

• Separate incision or excision

• Separate lesion

• Separate injury (or different area in cases of multiple injuries)

How to identify the procedure is distinct or seperate ?

Both 51 and 59 modifier will be used only if more than one procedure is performed. So Check NCCI edits, if edit came then it is distinct or if not then it is muliple.

How will payment get affected if you dont use 59?

The major reason for deny of the claim is not using 59 modifier. Modifier 59 is used to unbundle the service. There are two scneario for this, in once case you cant unbundle the second procedure in any scenario and in other case you can unbundle the second procedure by using 59 modifier.

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Difference between Modifier 51 and Modifier 59

The key points for reporting modifiers 51 and 59 are summarized as follows:

1. Modifiers 51 and 59 should not be appended to E/M codes, physical medicine and rehabilitation codes, or provision of supplies (eg, vaccine products).

2. Modifier 59 is reported instead of modifier 51 when two procedures or services may be reported together in defined circumstances that are not considered unbundling of a more comprehensive procedure.

3. Modifier 51 is reported instead of modifier 59 when two procedures or services are not considered unbundling and do not have a restriction for being reported by the same health care professional during the same session.

4. Modifiers 51 and 59 are appended only when another more descriptive modifier (eg, use of modifier 76) is not available.

5. Modifiers 51 and 59 are typically appended to the code with the lower total RVU, unless the code descriptor includes the term "separate procedure," in which case modifier 59 is appended to the code that is designated as a "separate procedure."

6. Third-party payers' reporting guidelines for these modifiers may vary from CPT reporting guidelines. Check with individual third-party payers to determine their guidelines for the use of these modifiers