# Cpt code 76642 billing bilaterally



## 1formissy

Ok, so this seems silly, however, sometimes when reviewing information, there is not always a cut and dry answer to questions. 
I know that billing CPT Code 73721 if the patient has both breasts done, you will report 73721 on two lines, and use RT, LT modifiers. 
However, that code is also subject to the bilateral reduction. Meaning the second CPT code, will be paid @ 50% OR if that code is reported one one line, and you append a modifier 50, than it will be reimbursed @ 150% of the allowed amount. 
If those codes are reported on two lines, RT, and LT, NCCI does NOT take a 50% reduction off the second line. So, it appears conflicting with me, that if you report on two lines with the RT and LT, there is no reduction, however, if you report on one line with the 50 modifier, you will get a %50 reduction. 
Am I making this more confusing than it should be?


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## chembree

There have been lots of issues with the way 76642/76641 is processed bilaterally. Below are a couple of known issues that you may want to check to see if they could be causing a difference in what you are seeing. If you are being paid differently I would suggest checking your contracts or contact your MAC. 

In October of 2016 Humana had a known issue of processing 76642RT and 76642LT & combining into 76642-50 but only paying for one

In 2016 the fee schedule updated them with a bilateral indicator of 1 (150% of fee schedule).   

CMS Reverts Back to a Bilateral Indicator 1 for Breast Ultrasound
The Centers for Medicare & Medicaid Services (CMS) has rescinded Transmittal 3364, dated September 29, 2015 and replaced with Transmittal 3407, dated November 18, 2015 to update the list of revisions to the “Quarterly update to the Medicare Physician Fee Schedule Database (October CY 2015 Update).” As noted in the associated MLN Matters MM9266, Document History, On November 25, the “What You Need to Know” section listing RVU changes was revised to remove several codes (76641, 76641-TC, 76641-26, 76642, 76642-TC, 76642-26) that had been listed with bilateral surgery indicator changes. 

The listing of the breast ultrasound codes in Transmittal 3364 with the assignment of a bilateral indicator of “3” [The usual payment adjustment for bilateral procedures does not apply] was in error. Therefore, CMS immediately corrected the error by issuing Transmittal 3407. The assignment of a bilateral modifier indicator of “1” [150% payment adjustment for bilateral procedures applies] was discussed in the CY2015 Medicare Physician Fee Schedule Final Rule (p. 67666, Federal Register, Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations), which stated:
One difference between the predecessor code [76645] and the new ones [76641, 76642] is that while the predecessor code was used to report unilateral or bilateral breast ultrasounds, the new codes are unilateral ones. To appropriately adjust payment when bilateral procedures are furnished under the PFS, payments are adjusted to 150 percent of the unilateral payment when a service has a bilateral payment indicator assigned. We are assigning a bilateral payment indicator to these codes.
Radiology practices are advised to contact their local Medicare Administrative Contractors on how to handle any overpayments made.

http://www.acr.org/Advocacy/Economi...a-Bilateral-Indicator-1-for-Breast-Ultrasound


0 	The 150 percent payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or with modifiers RT and LT, the payment is based on the lower of the total actual charge for both sides or 100 percent of the fee schedule amount for a single code. 
1 	The 150 percent payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. If the procedure is reported as a bilateral procedure and is also reported with other procedures on the same day, the bilateral adjustment is applied before applying any multiple procedure rules. 
2 	The 150 percent payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on the lower of the total actual charge for both sides or 100 percent of the fee schedule amount for a single code. 
3 	The usual payment adjustment does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on 100 percent of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, the fee amount for the bilateral procedure is applied before applying any multiple procedure rules. Note: This designation is primarily for radiology services or other diagnostic tests that are not subject to the special payment rules for bilateral surgeries. Radiology CPT codes and the applicable multiple procedure designations are contained in appendix B. 
9 	Bilateral procedure concept does not apply


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## daedolos

Thank you so much for the thorough reply.  This helps me with my ortho procedure coding.

Peace
@_*


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## 1formissy

Thank you, that was quite helpful.


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## BrettAAPC

chembree said:


> There have been lots of issues with the way 76642/76641 is processed bilaterally. Below are a couple of known issues that you may want to check to see if they could be causing a difference in what you are seeing. If you are being paid differently I would suggest checking your contracts or contact your MAC.
> 
> In October of 2016 Humana had a known issue of processing 76642RT and 76642LT & combining into 76642-50 but only paying for one
> 
> In 2016 the fee schedule updated them with a bilateral indicator of 1 (150% of fee schedule).
> 
> CMS Reverts Back to a Bilateral Indicator 1 for Breast Ultrasound
> The Centers for Medicare & Medicaid Services (CMS) has rescinded Transmittal 3364, dated September 29, 2015 and replaced with Transmittal 3407, dated November 18, 2015 to update the list of revisions to the “Quarterly update to the Medicare Physician Fee Schedule Database (October CY 2015 Update).” As noted in the associated MLN Matters MM9266, Document History, On November 25, the “What You Need to Know” section listing RVU changes was revised to remove several codes (76641, 76641-TC, 76641-26, 76642, 76642-TC, 76642-26) that had been listed with bilateral surgery indicator changes.
> 
> The listing of the breast ultrasound codes in Transmittal 3364 with the assignment of a bilateral indicator of “3” [The usual payment adjustment for bilateral procedures does not apply] was in error. Therefore, CMS immediately corrected the error by issuing Transmittal 3407. The assignment of a bilateral modifier indicator of “1” [150% payment adjustment for bilateral procedures applies] was discussed in the CY2015 Medicare Physician Fee Schedule Final Rule (p. 67666, Federal Register, Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations), which stated:
> One difference between the predecessor code [76645] and the new ones [76641, 76642] is that while the predecessor code was used to report unilateral or bilateral breast ultrasounds, the new codes are unilateral ones. To appropriately adjust payment when bilateral procedures are furnished under the PFS, payments are adjusted to 150 percent of the unilateral payment when a service has a bilateral payment indicator assigned. We are assigning a bilateral payment indicator to these codes.
> Radiology practices are advised to contact their local Medicare Administrative Contractors on how to handle any overpayments made.
> 
> http://www.acr.org/Advocacy/Economi...a-Bilateral-Indicator-1-for-Breast-Ultrasound
> 
> 
> 0 	The 150 percent payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or with modifiers RT and LT, the payment is based on the lower of the total actual charge for both sides or 100 percent of the fee schedule amount for a single code.
> 1 	The 150 percent payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. If the procedure is reported as a bilateral procedure and is also reported with other procedures on the same day, the bilateral adjustment is applied before applying any multiple procedure rules.
> 2 	The 150 percent payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on the lower of the total actual charge for both sides or 100 percent of the fee schedule amount for a single code.
> 3 	The usual payment adjustment does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with 2 in the units field), the payment is based on 100 percent of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, the fee amount for the bilateral procedure is applied before applying any multiple procedure rules. Note: This designation is primarily for radiology services or other diagnostic tests that are not subject to the special payment rules for bilateral surgeries. Radiology CPT codes and the applicable multiple procedure designations are contained in appendix B.
> 9 	Bilateral procedure concept does not apply



So, essentially it doesn't matter if you choose to submit with modifier 50 or LT,RT? Same payment regardless? The only issue is figuring out whether the insurance company will accept both formats, or they prefer one over the other?


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