Append modifier 51
Modifier usage is usually included in the findings, when we audit medical claims for accurate coding. Applying inaccurately and inappropriately of modifiers to CPT(C) codes could result in inaccurate payment of claims. Additionally, there are times when application of a modifier following CPT(C) principle will result in denied claims. When claims are received and processed electronically, payment logic may have been programmed to alleviate the need for personal review and decision making.
Coding principles tell us that modifier 51 should be appended 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 refer Appendix D.
As auditors, it is important to know and apply coding principles and frequently audit customers in receiving audit findings identifying the practice?s non-inclusion of modifier 51. From a coding perspective it is correct. Internal auditing staff may already have insight into these nuances but it is important in all cases to describe findings in a way that is useful.
The practical application of whether to append modifier 51 has changed over the years. Many payers have hard-coded their payment software to recognize a claim with 2 or more (not bundled) CPT(C) codes and have applied the 51 modifier logic without using the modifier. To use the modifier in such a case may result in claims denial due to the software?s inability to process claims with the modifier.
Where payers have provided instruction to *not* use modifier 51, an audit finding of a ?missing modifier? will, at best, be confusing to the practice. It could even lead the recipient to question the credibility of the other findings within the audit report.