Multiple Procedure Payment Reduction (Modifier 51) Policy Revision Effective August 1, 2024
MedCost continually reviews its reimbursement policies to ensure they align with industry standards. The following revised Multiple Procedure Payment Reduction (Modifier 51) policy will be implemented effective August 1, 2024.
Multiple Procedure Payment Reduction (Modifier 51)
When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s).
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Modifier 51 is defined as multiple surgeries/procedures performed during the same session by the same provider.
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This modifier should not be appended to designated "add-on" codes.
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Multiple surgeries/procedures include diagnostic imaging services that are provided on the same day during the same session by the same provider.
Appropriate System Usage
Modifier 51 is appended when:
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The same physician performs more than one surgical service at the same session (Indicator 2).
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The technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction rule applies (Indicator 4).
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The multiple surgical procedures are done on the same day but billed on two separate claims.
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The surgical procedure code is the lower physician fee schedule amount.
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The diagnostic imaging procedure with the lower technical component fee schedule amount.
Inappropriate System Usage
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Do not append to add-on codes (See Appendix D of the CPT manual).
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Do not report on all lines of service.
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Do not append when two or more physicians each perform distinctly different, unrelated surgeries on the same day to the same patient.
Additional Information
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MedCost will consider the procedure with the highest relative value unit (RVU) as primary. The procedure with the highest RVU should be listed first on the claim, and modifier 51 appended to the subsequent lower RVU procedure(s).
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Reimbursement will be 100% for the primary procedure and 50% each for the other code(s).
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Multiple surgery pricing also applies to assistant surgery services.
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Multiple surgery pricing applies to bilateral services (modifier 50) performed on the same day with other procedures.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, MedCost may:
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Reject or deny the claim.
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Recover and/or request a refund of claim payment.
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If no modifier is appended for MedCost Benefit Services, reimbursement may be adjusted to reflect the appropriate services and/or procedures performed.