Anesthesia Coding Alert

"The problem when you're coding for facet or transforaminal injections is that you have codes for first level and additional levels," says Robin Fuqua, CPIC, anesthesia coder for Jose Veliz, MD, in Escondido, Calif. "We believe that even if you're on one level when performing bilateral injections, you should still bill the case as a first-level and additional-level injection. Then we add -LT (Left side) or RT (Right side) to indicate the side being treated."

Other coders agree with this approach, saying that it's always important to indicate clearly the physician's services when bilateral modifiers come into play.

Example: The physician administers three blocks to the right of L3, then later administers three more blocks to the left of L3. Many carriers approve a maximum of three blocks per level. If you don't clearly document that the physician treated both sides of the joint, the carrier might think he administered six blocks to the same area and reject the claim.

Some physician or coding societies recommend coding bilateral procedures with both sets of modifiers. Some coders say that reporting modifiers -50, -LT and     -RT on the same claim is redundant, but they concede  that it's worth doing if you're following the carrier's guidelines.

Verify That It's a Same-Session Procedure

Any injections (or other procedures) that the pain management specialist performs must be administered during the same session before you can report a bilateral procedure. The practitioner must also inject the same site on both sides to qualify as a bilateral procedure.

Example: 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) is a common unilateral injection code. If the physician administers the injections bilaterally, you report the procedure as 64470-50 to indicate that he treated both sides of the area.
 
"Bilateral procedures are done during the same session and are a mirror image of each other," says Barbara Johnson, CPC, MPC, owner of the consulting firm Real Code Inc., in Moreno Valley, Calif. "That means the physician injects the same level on each side."

However, if the physician administers the injections during separate patient visits, modifier -50 doesn't apply. If the provider administers the cervical injections in the example above to opposite sides of the same site but at different times, code each as a stand-alone procedure with 64470. Tip: Some coders recommend appending modifiers -LT/-RT to help document which area the physician treated and to distinguish between the visits.

Follow Carrier's Preference for Bilateral Modifiers

Another checkpoint when coding bilateral procedures is whether you're reporting the correct bilateral modifier. Modifier -50 is the most commonly used, but that's not your only option.

CPT also includes modifiers -LT and -RT to indicate where a procedure is performed. Some carriers prefer these modifiers to designate bilateral procedures, so verify each carrier's preference before coding.

Example: Most Medicare carriers require modifier -50 for bilateral facet injections, transforaminal epidurals and similar procedures; other carriers prefer that you report single line items with -LT and -RT instead. Some coders also prefer -LT and -RT because they help clearly document that the physician treated both sides of the same area.

So are there advantages to reporting -LT/-RT instead of modifier -50? Your payment is the same for either option, but some coders say that appending -LT/-RT can help ensure that you code correctly. "This way you can list each injection as a separate line item with its own charge instead of trying to remember to increase the charge when you report modifier -50," Fuqua says. "It's also easier to read the EOB and verify that you were paid correctly for each injection."

But some experts advise against using modifiers -50 or -LT/-RT, Fuqua says. Instead, they recommend using the procedure code twice (if the procedure doesn't use an add-on code for additional levels), and adding modifier -59 (Distinct procedural service) to indicate that the two line items represent separate procedures.
 
Example: Fuqua sometimes codes procedures in which the physician administers two injections into the same shoulder at different points. She submits the cases with an operative report, but also includes a note on the claim form to clarify the procedure: "20610 = RT shoulder acromioclavicular joint injection; 20610-59 = RT shoulder intra-articular joint injection."

If the physician performs bilateral facet or transforaminal injections, she reports the first injection with the main code (64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) with the appropriate -LT/-RT modifier. Then she codes the second injection with add-on code +64484 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]) and either -LT or -RT.
 
The bottom line with bilateral procedures is to know how each carrier expects you to code it. Whether you report a single unilateral code with modifier -50, report the code twice with modifier -50 on each line, or append modifiers -LT and -RT, following the carrier's guidelines can help you correctly report cases and get appropriate reimbursement.