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Medical Coding News Archives

Modifier 51 Revisions Affect the Bottom Line

December 26, 2007:
New criteria for making a code subject to lower payment because of multiple procedures mean that the appropriate reductions will now apply to additional codes. This, in turn, means a reduction in payment and a hit to some providers’ bottom lines.

For 2008 the CPT® Editorial Panel and the Relative Value System Update Committee (RUC), both of which are American Medical Association entities, developed new criteria for when a procedure code should be considered ineligible for multiple procedure reduction (51 modifier exempt). The Centers for Medicare and Medicaid Services (CMS) reviewed the findings of the two committees and supported their recommendations in the 2008 final rule.

The criteria establishing that a code is adjunctive to another procedure and should not be reduced when performed with said procedure are as follows:
  • There is little if any pre- and post-service time built into the RVU for the procedure.
  • The procedure is not an add on code:
    • Pre- and post-service time is not built into the RV for add-on codes by definition, so there’s no need to say the same thing twice. See appendix D for add on codes and note movement of codes from appendix E to appendix D (list follows).
  • The procedure cannot have any established payment logic that makes payment reduction a moot point:
    • Immune globulin codes
    • Vaccine/toxoid codes
    • Physical medicine and rehabilitation codes
    • MPR established by CMS in the MPFS/Medicare payment rule
Because of the revisions, there are a significant number of 2008 codes that are no longer modifier 51 exempt. Those codes with a large amount of pre- and post-service times in the relative value include 20660, 20690, 20692, 20900, 20902, 20910, 20912, 20920, 20922, 20924, 20926, 32421, 32422, 32551, 36660, 61210, 62284, 93505, 93508, 93510, 93511, 93514, 93524, 93526, 93527, 93528, 93530, 93531, 93532, 93533, 93541, 93542, 93543, 93619, 93620, 93624, 93640, 93641, 93642, 93650, 93651, 93652, 93660, 99148, and 99149.

Add on codes no longer modifier 51 exempt are 20930, 20931, 20936, 20937, 20938, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22851, 33517, 33518, 33519, 33521, 33522, 33523, and 35600.

Deborah C. Hall
Clinical/Technical Editor

CPT is a registered trademark of the American Medical Association.


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