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Please note that mild lactic acidosis or ketoacidosis can occur, but it isnt sufficiently severe to explain the anion gap: Lactic acidosis

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Modifier-51 is the most commonly applied modifier under the PFS, and it typically reduces the payment of a second (and any subsequent) procedure if conducted on the same patient on the same day, most often with the most expensive procedure getting paid in full and additional procedures having their payment cut in half