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MULTIPLE SURGERY BILLING GUIDELINES

THE APPROPRIATE APPLICATION OF MODIFIER 51 FOR WELLCARE CLAIMS

Unlike the other insurances Wellcare will not systematically apply the Modifier 51 to a claim line when the multiple surgery reduction rules apply. Wellcare will deny the claim and require the provider to re-submit the claim with the Modifier 51. Hence modifier 51 should be used when billing multiple procedures on the same day, during the same surgical session, or on 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 Modifier 51 Application:

Multiple Procedures

When the same physician performs more than one surgical service at the same session.

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 Work RVU value.

Diagnostic Imaging Services

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 column in the MPFSDB (Medicare Physician Fee Schedule Data Base)

When the MPFSDB indicates a “01–11” in the Diagnostic Imaging Family Indicator column.

Append Modifier 51 to the diagnostic imaging procedure with the lower technical component Work RVU value.

Look up here to view the indicators...

Do Not Use Modifier 51:

Do not use Modifier 51 on designated add-on codes.

Do not report Modifier 51 on all lines of service.

Wellcare reimbursement for multiple procedures

Wellcare pays for multiple surgeries as follows:

100% of the highest physician fee schedule amount

50% of the physician fee schedule amount for each of the other codes (2-4) and 25% thereafter

Reference: http://wellcare.com/WCAssets/corporate/assets/ProviderNewsletter_FL_2010IssueIII.pdf

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