Modifier 51 Hints: Your Go-To Guide for the MPFS Multiple Procedure Column

understand modifier 51 payment adjustments

There are nine different Multiple Procedure indicators on the Medicare Physician Fee Schedule (MPFS), meaning there are a lot of payment adjustment possibilities you need to know. Here’s each indicator, an example of a code with that indicator, and a quick look at where modifier 51 comes into play.

What Is Modifier 51?

The basic idea behind modifier 51 (Multiple procedures) is that it alerts a payer that there’s a potential overlap between services and therefore RVUs. Knowing that, the payer can adjust payment to better reflect the resources used.

For instance, way back in 2008, CPT® Assistant (vol. 18, issue 7) gave the example of performing these two services at the same session:

  • 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s]), ([eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar)
  • 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)) (22612’s code descriptor has changed slightly since 2008 and the current descriptor is used here).

Both codes have 90-day global periods and can require substantial follow-up work, but when the post-op visits are combined for the two procedures, the time required to perform the visits is reduced, so the argument is that it makes sense to reduce the RVUs, too.

Reality: Many payers, including Medicare, instruct you not to apply modifier 51 because their software calculates appropriate (possibly reduced) payment when you report multiple procedures. Before you append modifier 51, confirm your payer’s rules.

What Are the Multiple Procedure Indicators?

Below are abbreviated definitions for MPFS multiple procedure indicators based on the 2019 Q3 MPFS. (To see complete definitions from this source, download the zip file at the linked site, and open the PDF titled “RVU19C.” Multiple Procedure definitions start on page nine.) The code examples are based on indicators also in the 2019 Q3 MPFS, effective July 1, 2019. Indicators are subject to change quarterly, so make sure you’re using the correct data for your date of service.

0, No payment adjustment rules for multiple procedures apply …

Example: Add-on code +19286 (Placement of breast localization device(s) …) has indicator 0. Add-on codes are valued with the knowledge that they’ll be reported in conjunction with another code, so payment adjustment to reflect multiple procedures isn’t needed.

1, Standard payment adjustment rules in effect before January 1, 1995 for multiple procedures apply …

Example: This is more of a historical indicator.

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) …

Example: Code 43762 (Replacement of gastrostomy tube …) has indicator 2. So pay attention to the potential 50 percent fee reduction depending on the indicators for the codes you report along with 43762.

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) …

Example: Category III code 0499T (Cystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed) has indicator 3. This example is a good reminder that even temporary Cat. III codes with coverage indicator C (MAC priced code) may have payment adjustment rules assigned in the MPFS. For more information about this indicator, see our blog post about the MPFS multiple endoscopy rule.

4, Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced procedure, and 50% for each subsequent procedure …

Example: Code 70336 (Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)) has indicator 4.

5, Subject to 50% of the practice expense component for certain therapy services.

Example: Code 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual) has indicator 5.

6, Subject to 25% reduction of the second highest and subsequent procedures to the TC of diagnostic cardiovascular services …

Example: Code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) has indicator 6.

7, Subject to 20% reduction of the second highest and subsequent procedures to the TC of diagnostic ophthalmology services …

Example: Code 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only) has indicator 7.

9 = Concept does not apply.

Example: Code 80048 (Basic metabolic panel (Calcium, total)) has indicator 9. Like many codes with indicator 9, 80048 has status X (Statutory exclusion) and isn’t paid under the MPFS.

What About You?

Do you factor the multiple procedure rule into your coding?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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