Question: I am new to facility coding and have some questions on how to report bilateral procedures in an ASC setting. Does modifier 50 still apply?
New York Subscriber
Answer: Payers don’t observe consistent, across-the-board policies regarding bilateral procedure reporting. Although modifier 50 (Bilateral procedure) is on the list of modifiers approved for outpatient use, some payers (including Medicare) direct ASCs not to report modifier 50 and instead instruct you to report a bilateral procedure using two units of the applicable CPT code.
Specifically, Medicare guidelines instruct, "bilateral procedures should be reported as a single unit on two separate lines or with ‘2’ in the ‘units’ field on one line, in order for both procedures to be paid." "Use of the 50 modifier is not prohibited," CMS cautions, but "the modifier will not be recognized for payment purposes and may result in incorrect payment to ASCs."
Example: An otolaryngologist performs ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]: APC 0075) on both the right and left sinuses in the ASC setting. In this case, rather than reporting 31255-50, the ASC coder would report 31255 x 2.
To further clarify the claim, you could append modifier LT (Left side) to the first unit of 31255 and modifier RT (Right side) to the second unit of 31255.
Private payers may direct you to report modifier 50 in the same fashion that you would apply the modifier for physician billing.
Example: In an identical case to that described in the example above, the otolaryngologist performs ethmoidectomy on the right and left sinus in the ASC setting. Because of payer preference, however, you would report 31255 on the first line and a second unit of 31255 with modifier 50 appended:
Line 1: 31255
Line 2: 31255-50.
Some payers may even direct you to report only a single line item with modifier 50 appended (for example, 31255-50) to describe a bilateral procedure.
Bottom line: Proper bilateral procedure reporting -- and modifier 50 application -- is payer-specific for ASCs. Be sure to consult your individual payer for its guidelines, and follow those instructions to the letter.
