Multiple Surgical Procedures

In some groups, the coder performs all of the steps below.  The responsibilities indicated here are opinion of the author, not law, regulation or national policy.

Physician Responsibility:

1.    List all codes for the procedures performed

2.    Note whether the procedures performed were done via the same compartment, incision, site, organ system, lesion, injury, session and by the same surgeon.  If all are the same, note "same."  If any of the above were different, note "different."

Coder Responsibility:

3.    Check the Relative Value Units for each procedure, and note them next to the code.  The code with the highest RVU is the primary procedure.  The others are secondary procedures.  Note the primary procedure.

4.    Check the CCI edits.  If the secondary procedures are component codes of the primary procedures, and the procedure was the same (as indicated above), bill only the primary procedure. Use the current version of the NCCI edits.

5.    If the secondary procedures are not component codes of the primary procedure, and the procedure was the same (as defined above), bill the primary procedure with no modifier, and the secondary procedures with -51 modifier.  This indicates that multiple procedures were performed that fall into the category of "same" as indicated above. (Not all payers required/want –51 modifier on a claim)

6.    If the secondary procedures are component codes of the primary procedure, but the procedure meets the different criteria above (different session, compartment, lesion, injury, etc) bill the primary procedure with no modifier and bill the secondary procedures with a -59 modifier.

Payment implications:

Payers will not pay for bundled procedures separately if performed through the same incision, etc.  Modifier -59 tells the payer that even though this is a bundled procedure, it is separately payable (within the multiple procedure reductions) because it was a different session, incision, compartment etc.  It tells the payer:  this is not a duplicate or repetitive submission. It is a component code of the primary procedure, but pay it because it is a different session, site, compartment, incision, etc.

Medicare tells us that modifier 59 is the modifier of "last resort."

Using modifier 51 allows you to be paid for multiple procedures in the same day that are not bundled together.  Medicare payers do not require modifier 51 on the claim form,  Commercial payer policy varies.