Modifier 51

Modifier 51 Description, Uses, Guidelines & Examples (2022)

Modifier 51 appends for the service when the same physician performs multiple procedures on the same day in a single encounter.

Modifier 51 Description

Modifier 51 appends for the service when the same physician performs multiple procedures in a single encounter on the same day. 

It frequently bills in surgical service and always append to the secondary procedure code regarding RUVS. 

Modifier 51 does not apply to the Evaluation and Management CPT codes (99201-99499). Therefore, it is appropriate to append modifiers 24, 25, 57, etc., when E/M visits bills for the service. 

Modifier 51 applies with Medicine Chapter CPT codes when the same physician performs multiple procedures in the same encounter. 

Modifier 51 appends to represent the second or subsequent procedure performed on the same day to the insurance or third-party payer. The insurance may apply a reduction in the payment as a multiple procedure discount in the same encounter.

Modifier 51 applies when the physician performs on different or same sites by the same physician in the same encounter. It only applies when the physician performs multiple visits in the same session. 

51 modifier

What Is Modifier 51?

Modifier 51 appends with CPT codes to represent the multiple procedures performed in the same encounter on the same day. Modifier 51 always attaches to secondary or subsequent services when performed on the same day by the same physician.

When To Use Modifier 51

The followings are vital points when modifier 51 applies to the procedure code. 

The physician performs two or more procedures at the same encounter. The 51 Modifier attaches to the secondary and subsequent procedure. 

The physician may perform multiple procedures on the same patient at different sites in a single encounter. The 51 attaches to the secondary and subsequent service. 

The physician may perform multiple procedures on the same patient at the same sites in a single encounter. The modifier 51 attaches to the secondary and subsequent service. 

Modifier 51 Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

Modifier 51 should not apply to the highest RUVS CPT codes, leading to reduced payment. Instead, the proper way is to bill the highest RUVS CPT code without 51 and then report 51 Modifier to secondary or subsequent procedures.

Modifier 51 does not apply to evaluation and management procedures (99201-99499). It is appropriate to report with 25, 24, 57, etc. For Instance, the physician presents to the office with a head injury in the evaluation and management settings and performs the head procedure on the same E/M visit. It is appropriate to report E/M visit with modifier 57 instead of 51.

Modifier 51 is inappropriate to append with CPT codes listed in the AMA CPT code book (APPENDIX E). This index provides the list of CPT codes exempt from modifier 51.

The order of CPT codes plays a significant role in the reimbursement of the services in RUVS. Therefore, the primary procedure code should always be listed first.

51 Modifier is inappropriate to append with Add-on CPT code codes listed in the AMA CPT code book (APPENDIX D). This index provides the list of add-on CPT codes exempt from 51.

Modifier 51 does not apply to the services requiring modifier 50 for the bilateral procedures because it covers the reimbursement of both sides’ services. 

What Type Of CPT Code Is Modifier 51 Exempt?

The Symbol circle with the slash “Ø” indicates that the CPT code is exempt from modifier 51, such as CPT codes 19084, 64462, etc. In addition, add-on CPT codes are exempt from 51, and they cannot append with these CPT codes. Appendix E in the AMA CPT code book provides a detailed list of CPT codes with a summary that is exempt from modifier 51. 

If the physician performs the bilateral procedure and modifier, 50 is appropriate, and It is not applicable to bill with 51.

Add-on code is always used in addition to the primary procedure CPT code book and cannot code as the first listed procedure. Therefore, the symbol “+” represents add-on codes in the CPT code book.

Modifier 51 vs 59

Modifiers 59 and 51 indicate multiple procedures and services performed on the same day in a single encounter but for different intents. 

Modifier 51 applies to the service when different procedures furnish in the same session. For example, a single operation performed multiple times at various sites, or a single service performed numerous times at the exact location.

Attaching 51 Modifier with the procedure, evaluation, and management CPT codes when performed is irrelevant. However, it may influence the payment of the service and make reductions with other procedures performed on the same day. It is significant to report high-dollar claims first to get higher prices from the insurance carrier.

In Contrast, Modifier 59 applies to the services performed in a different session or encounter on the same day. This procedure is distinct from the other service, anatomical site, separate incision, excision, injury, or body location. 

Attaching modifier 59 with the procedure when performing, evaluating, and managing CPT codes is also irrelevant. It is not appropriate to the bill when an established modifier is available.

List Of Idicators

The below Indicator indicates which payment adjustment rule for multiple procedures applies to the service.

Indicator 0 (Multiple Surgery)

No payment adjustment rules for multiple procedures apply. If 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.

Indicator 1 (Multiple Surgery)

Standard payment adjustment rules in effect before January 1, 1996, or 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.

Indicator 2 (Multiple Surgery)

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 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.

Indicator 3 (Multiple Surgery)

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 field 31G. 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.

Indicator 4 (Multiple Surgery)

Subject to 25% reduction of the TC diagnostic imaging (effective for services on or after January 1, 2006 through June 30, 2010).

Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after).

Subject to 25% reduction of the professional component (26 modifier) diagnostic imaging (effective for services January 1, 2012 and after).

Indicator 5 (Multiple Surgery)

Subject to 20% reduction of the practice expense component for certain therapy services (effective for services January 1, 2011 and after).

Indicator 6 (Multiple Surgery)

Subject to 25% reduction for subsequent TC services furnished by same physician (or by multiple physicians in same group practice, i.e., same Group NPI) to same patient on same day. (Cardiovascular Services).

Indicator 7 (Multiple Surgery)

Subject to 20% reduction for subsequent TC services furnished by same physician (or by multiple physicians in same group practice, i.e., same Group NPI) to same patient on same day. (Ophthalmology services)

Indicator 9 (Multiple Surgery)

Concept does not apply. Do not submit these procedures with CPT modifier 51

Inappropriate Usage Of Modifier 51

Modifier 51 appended to designated “add-on” codes.

Reporting on primary procedures and on base endoscopy procedures.

Reporting to Evaluation and Management (E&M) CPT codes.

Reporting to Physical Medicine and Rehabilitation services or provision of supplies (eg.vaccines).

Appending Modifier 51 to a CPT designated 51 Exempt procedure code.

Appending 51 Modifier to procedures that are considered components of the primary procedure.

Appending 51 in instances when two or more physicians each perform distinctly different, unrelated surgeries on the same day for the same individual.

Appending Modifier 51 when a more appropriate modifier exists to more accurately describe the scenario being reported.

Return to List of All Modifiers

Modifier 51 Examples

The following are the examples of when 51 appends with the CPT codes:

Example 1

A 36-year-old male presents to the physician for Colonoscopy and upper endoscopy procedure in the same physician session. Suppose CPT codes 45378 and 43200 bills for these services. These CPT codes 45378 and 43200 are generally not billed together on the same day, but a modifier is allowed with these CPT codes.

CPT 45378 is a primary procedure code without modifier 51 and 43200 with 51. Modifier 51 appends with CPT code 43200 to unbundle the service with CPT code 45378. 51 appends with CPT 43200 because of lower RUVS. 

If CPT codes 45378 and 43200 performs by a different provider, It is inappropriate to add 51 Modifier with CPT 43200 in the postoperative period. CP 43200 may bill without any modifier and get full reimbursement for the claim.

If CPT codes 45378 and 43200 performs by the same provider but in distinct locations. For example, If the physician performs an endoscopy of the heart instead of upper GI endoscopy, It is appropriate to report 59 instead of 51.

Documentation must support the medical necessity of these two services, Colonoscopy, and upper endoscopy procedures, on the same day for accurate reimbursement by the insurance or third-party payer.

Example 2

A 46-year-old male presents to the physician for excision, malignant lesion, trunk, 0.5cm or less (11600), and intermediate repair (layer closure) of wounds of the chest, 5.0 cm(12032).

Suppose CPT codes 11600 and 12032 bills for these services. According to NCCI, these CPT codes 11600 and 12032 are generally not billed together on the same day. Therefore, a modifier is allowed with these CPT codes.

CPT 12032 is a primary procedure code without modifier 51 and 11600 with 51. Modifier 51 appends with CPT code 11600 to unbundle the service with CPT code 12032. 51 Modifier appends with CPT 11600 because of lower RUVS. 

If CPT codes 12032 and 11600 performs by different providers, It is inappropriate to add 51 with CPT 12032 in the postoperative period. CPT code 12032 may bill without any modifier and get full reimbursement for the claim.

If CPT codes 12032 and 11600 performs by the same provider but in distinct locations. For example, If the physician performs wound closure on the head or neck region instead of the trunk region, It is appropriate to report modifier 59 instead of 51.

Documentation must support the medical necessity of these two services intermediate repair (layer closure) of wounds of the trunk and excision of a malignant tumor on the same day for accurate reimbursement by the insurance or third-party payer.

Example 3

A 76-year-old male presents to the physician for incomplete abortion completed surgically (58912) and insertion of an IUD (58300). Suppose CPT codes 58912 and 58300 bills for these services. A modifier is allowed with these CPT codes. According to NCCI, these CPT 58912 and 58399 codes are generally not billed together on the same day.

CPT 58912 is a primary procedure code without 51 and 58300 with modifier 51. Modifier 51 appends with CPT code 58300 to unbundle the service with CPT code 58912. 51 appends with CPT 58300 because of lower RUVS. 

If CPT codes 58912 and 58300 performs by different providers, It is inappropriate to add 51 with CPT 58300 in the postoperative period. CPT code 58300 may bill without any modifier and get full reimbursement for the claim.

If CPT codes 58912 and 58300 performs by the same provider but in distinct locations. For example, If the physician places an ET tube instead IUD device on the same day, It is appropriate to report 59 instead of 51.

Documentation must support the medical necessity of these two services incomplete abortion completed surgically and insertion of an IUD on the same day for accurate reimbursement by the insurance or third-party payer.

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