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The Differences Between Modifiers 51 and 59

Mary LeGrand, RN, MA, CCS-P, CPC


One of the most frequently asked question about modifiers is When do I use modifier 51 and
when do I use modifier 59? This article differentiates the use of these modifiers when two or
more procedures are performed on the same day.
About modifier 51
Modifier 51 (multiple procedures) is used to inform payers that two or more procedures are
being reported on the same day. A claim form (CMS 1500) that has modifier 51 appended to a
CPT code(s) tells the payer to apply the multiple procedure payment formula to the CPT code(s)
linked to the modifier 51, assuming the payer accepts this modifier.
Some payers may not accept or require the use of this modifier because their computer systems
are already programmed to automatically apply the multiple procedure reduction to the
lesser-valued code(s). It is important to remember the following conditions that apply to the
use of modifier 51:
No special rules related to the reporting of the code combinations can apply.
The CPT code(s) cannot be an add-on (CPT Appendix D) or modifier 51 exempt (CPT
Appendix E) codes.
The CPT code(s) must be stand-alone procedures and not inclusive to other procedures
performed at the same time.
Unless your contract with the payer includes a carve out, the subsequent procedure(s)
is(are) subject to the payers multiple procedure payment formula.
The following examples show correct coding and appropriate use of modifier 51; special coding
rules (other than documentation of the work and medical necessity) are not required to report
the code combination.
Joint injections
Table 1 shows the coding that should be used when a physician performs a joint injection to a
major joint (20610) and joint injection to an intermediate joint (20605) during the same

session.
By definition, these two codes are stand-alone codes; their descriptions identify them as two
separate anatomic locations, and no specific coding rules must be met (other than
documentation and medical necessity). Both are subject to the multiple procedure payment
reduction.
Arthroscopic shoulder surgery
Table 2 shows the coding that should be used when a physician performs an arthroscopic
rotator cuff repair (29827), arthroscopic distal clavicle resection (29824), and arthroscopic
subacromial decompression (29826) during the same session.
All three procedures, although performed in the same shoulder, are considered to be in three
separate anatomic locations and are differentiated as such by their descriptions. CPT codes
29827 and 29824 are considered stand-alone codes; CPT code 29826 is an add-on code.
Add-on codes may only be reported with an index code (2980629825, 29827, or 29828) and
are not subject to the multiple procedure payment formulas. A modifier 51 is never appended to
an add-on code. The only coding rule (other than documentation and medical necessity) that
must be met to report this combination is the presence of an arthroscopic parent or index code
to allow CPT code 29826 to be reported.
Modifier 51 is appended to CPT code 29824 as the most appropriate modifier because it is a
concomitant, stand-alone procedure and is subject to the multiple procedure payment
reduction.
Spine surgery
Table 3 shows the appropriate coding for a posterolateral fusion at L3-L4 and L4-L5 (22612,
22614), laminectomy, facetectomy, foraminotomy and decompression at L3-L4 and L4-L5
(63047, 63048), posterior segmental instrumentation at L3-L5, and bone graft harvested from
the iliac crest (20937).
CPT codes 22612 and 63047 are both stand-alone codes; when reported together, the
lesser-valued procedure is subject to the multiple procedure payment formula. CPT codes
22614, 63048, 22842, and 20937 are add-on codes and are not subject to the multiple
procedure payment formula. To report these add-on codes, a parent or index code must be
present. CPT code 22612 is a parent code to 22614, 22842, and 20937. CPT code 63047 is a
parent code to 63048, 22842, and 20937.
A laminectomy is not considered inclusive to the posterolateral fusion (22612) and special
coding rules (other than documentation and medical necessity) do not have to be met to report
this code combination. Thus, modifier 51 is the most appropriate modifier to append to the
subsequent (lesser-valued) procedure.
To summarize, modifier 51 is appended to a subsequent procedure that is considered a

stand-alone code (not an add-on or exempt code) when the following conditions are met:
Two or more code combinations are reported.
By definition, the reported codes stand alone.
Special rules do not have to be met to report the code combination.
Modifier 59
Modifier 59, the distinct procedural service modifier, is reported with a CPT code combination
when a coding rule has to be met, when another, more specific modifier (multiple-51 or
bilateral-50) will not explain the situation to the payer, or when the code combination is correct,
but the payer has a reimbursement edit in place.
According to CPT, modifier 59 is used to support a different session, a different procedure or
surgery, a different site or organ system, a separate incision or excision, a separate lesion, or a
separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed
on the same day by the same individual.
Of critical importance and differentiation is the following statement from CPT: When another,
already established modifier is appropriate, it should be used rather than modifier 59. Only if no
more descriptive modifier is available, and the use of modifier 59 best explains the
circumstances, should modifier 59 be used. Thus, if the bilateral or multiple procedure
modifiers describe the situation, modifier 59 should not be usedeven in cases of a different
procedure, a different site, a separate incision, or a separate injury.
The following examples show when modifier 59 should be used because, according to CPT, a
coding rule has to be met to report a code combination, modifiers 51 or 50 will not adequately
explain the scenario, and the code combinations are reportable together under CPT rules, but
Medicare has issued a payment edit (Correct Coding Initiative, or CCI).
To meet a CPT coding rule
To report a chondroplasty during the same surgical session as a meniscal repair on the same
knee, the chondroplasty must be performed in a different compartment than the meniscal
repair. If the chondroplasty is performed in the same compartment as the repair, the
chondroplasty is not separately reportable.
For example, the surgeon documents a chondroplasty performed in the medial and
patellofemoral compartments and a meniscal repair in the medial compartment. Modifier 59 is
appended to the chondroplasty code to tell the payer that the coding rule to report the
chondroplasty (different site) was met (Table 4).
The goal in this case is to obtain reimbursement for the chondroplasty. Reimbursement is
expected to be reduced unless a contractual agreement is in place that allows for full
reimbursement.

To report the chondroplasty, the coding rule for the separate site must be met. Modifier 59 is
linked to the chondroplasty to indicate to the payer that the coding rule has been met. Because
modifier 51, the multiple procedure modifier, does not indicate that the coding rule was met, if
it were used, a denial as a bundled service would be expected.
Note: This coding combination is based on CPT coding rules. Some payers, such as Medicare,
may require reporting a G code (G0289) for the chondroplasty instead of the CPT code (29877).
To best explain the scenario
Consider the following situation: The surgeon documents injections to the right hip joint and the
right knee joint on the same day. Both procedures are defined by CPT code 20610.
Modifier 50, indicating a bilateral procedure, cannot be used because the injections are on the
same extremity at different joints. Modifier 51, indicating multiple procedures, does not
differentiate the injections as being in different locations; if it is used, the second procedure
might be denied as a duplicate submission. Modifier 59 is the correct modifier to use because it
not only indicates a separate site, it also meets the rule when a more descriptive modifier will
not explain the circumstances, then modifier 59 is used.
The goal is to be reimbursed for the second injection; a payment reduction should be expected
because it is a second procedure performed during the same session, thus triggering the
multiple procedure payment reduction.
Addressing a payment edit
In this scenario, a combination of CPT codes describes the procedures, with each code standing
alone and describing different anatomic locations, but Medicare has a payment edit in place.
For example, the documentation shows that the surgeon performed a right wrist injection and
an injection at the origin/insertion site of the tendon for lateral epicondylitis. Under the
American Medical Associations CPT rules, the surgeon would report codes 20605 for the wrist
injection and 20551-51 for the tendon injection. However, under Medicare payment rules, the
surgeon must report 20605 and 20551-59.
According to the CPT rules, these two codes represent procedures performed at separate
anatomic locations and should be reported using modifier 51. However, Medicare has an edit in
place to ensure that, when this code combination is reported, the surgeon must meet distinct
procedural rules for Medicare to consider payment. Because Medicare wants to ensure that the
surgeon is not reporting 20551 for the injection of the anesthetic agent at the site of, and prior
to, the wrist injection, it requires the use of modifier 59 in conjunction with a separate diagnosis
for payment to be processed for both procedures. Again, the goal is to be reimbursed for the
second injection; a payment reduction should be expected because the multiple procedure
payment reductions will typically apply.
Next steps
Orthopaedic practices should review their coding to ensure that modifiers 51 and 59 are being

used appropriately to reflect the procedures submitted to payers. Some payers may not accept
either modifier, which presents challenges for correct coding. Practices should avoid using
modifier 59 with the sole intent of overriding a payer edit. Medicare CCI payment edits are not
inclusive and do not contain all possible code combinations because Medicare assumes correct
coding.
The AAOS offers a coding consultation service (www.aaos.org/coding) and cosponsors coding
courses with KarenZupko & Associates (www.karenzupko.com/ortho.html). Orthopaedic
surgeons and coders are encouraged to take advantage of these resources when they have
coding questions.
Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc.,
who focuses on coding and reimbursement issues in orthopaedic practices. Information in this
article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement
Committee.
If you have questions about coding or want to suggest a topic for a future coding article, email
aaoscomm@aaos.org
AAOS Now
June 2013 Issue
http://www.aaos.org/news/aaosnow/jun13/managing2.asp

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