Q: I have always been under the premise that when billing 98943, extraspinal chiropractic manipulation, on the same visit as spinal manipulation, 98940-98942, that the extraspinal manipulation requires modifier 51. However, I recently received a denial from UnitedHealthcare stating that the modifier was improper. Is there a requirement to use the 51 modifier with this combination of coding?
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 or codes tells the payer to apply the multiple procedure payment formula to the CPT code(s) linked to the modifier 51. Therefore, in actuality it is not to inform that a separate service was done, but that multiple procedures were done and that a fee reduction applies. This is why UnitedHealthcare reduced the fee of 98943 by 50 percent, as use of the 51 modifier indicated such.
Clearly, 98940-98942, compared to 98943, are distinctly separate, as the former codes indicate manipulation to the spine and the latter to an extraspinal region. Clearly and based on the code description, a modifier is not needed to indicate they are separate, and if it were, the modifier would be 59, not 51. Per the CPT description and definition of modifier 51, it is not appropriate for use with E&M services or physical medicine rehabilitation services.
Of course, chiropractic manipulation is neither an E&M code nor a physical medicine rehabilitation service, but would appear to fall in the same range, so likely it also should not be used.
So, why would a carrier require the 51 modifier for a CMT as a multi-procedure when it is not used for any other services that fall under physical medicine? The answer appears to be simply that it allows for a 50 percent reduction of the fee. In my opinion, the use of 51 always appears inappropriate, as the services are clearly separate; and while the pre-manipulation assessment associated with CMT is part of the overall service, there is distinctly a separate pre-manipulation to extraspinal regions that would not be included in the spinal regions.
Furthermore, there should not be any reduction of the fee to extraspinal simply because spinal manipulation is done. The pre-manipulation assessment for the spine does not include what is necessary to assess or manipulate an extraspinal region, so a fee reduction on that basis seems improper.
While many, if not most carriers have abandoned the need for and use of the 51 modifier, several carriers have maintained the requirement, including UnitedHealthcare (Optum Health), as you noted. However, it recently eliminated the need to do so after the AMA made a definitive statement on the topic.
According to "The CPT Assistant" [December 2013], "these are separate and distinct procedures, and the use of Modifier -51 (Multiple Procedures) does not apply. Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940-98943)." Due to the definitive nature of the publication relative to coding of CPT, this means modifier 51 does not apply and more importantly, neither does the 50 percent reduction of payment.
UnitedHealthcare has subsequently published that there is no longer a need for the use of the 51 modifier for extraspinal chiropractic manipulation when done in conjunction with spinal manipulation.
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