General Surgery Coding Alert

When your general surgeon performs a bilateral surgery, don’t jump to conclusions and automatically append modifier 50 (Bilateral procedure) to the procedure code.

Read on for some expert guidance about when you should — or shouldn’t — turn to modifier 50.

Look at Code Descriptor

Some procedure descriptors already allow for bilateral procedures, which means modifier 50 probably is not appropriate.

Do this: “Look at the CPT^® descriptor for the code to which you are thinking of appending modifier 50,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “If the descriptor includes the word ‘bilateral,’ you should probably not append modifier 50.”

For instance: A laparoscopic total pelvic lymph node dissection is inherently bilateral (38571, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy). You should never use modifier 50 with 38571 or other bilateral codes.

You might apply modifier 50 to a code when the service is not designated as bilateral but the physician can perform it on an anatomic structure or organ that is symmetrical (like the nose or the cheeks) or that is paired (like the arms, legs, or ears), according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/ credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Example: If your surgeon performs injections in both wrists for carpal tunnel syndrome (20526, Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel), you can append modifier 50 to the code because the definition does not mention laterality.

Never: You should not append modifier 50 to an add-on code under any circumstances. You can identify those codes by the + symbol associated with the code, and by looking at a list of add-on codes in CPT^® Appendix D.

Follow Payer Guidance

The Medicare Physician Fee Schedule contains information about how to address bilateral procedures by listing one of the following bilateral procedure indicators for each surgical procedure:

• 0 - You cannot append modifier 50, but you can append LT or RT [for left or right]
• 1 - You can append modifier 50
• 2 - The code already specifies a bilateral procedure, so you should not append modifier 50, LT or RT to denote a procedure’s bilateral nature
• 3 - When performed bilaterally, append modifier 50 or LT/RT. Reimbursement is determined at 100 percent of the allowed for each side

You can see that for Medicare claims, bilateral billing is only appropriate when the bilateral surgery indicator for a particular code is “1” or “3.” You should check with other payers to see if they have similar rules for billing bilateral procedures.

Caveat: Knowing when it’s appropriate to submit a bilateral claim according to the Medicare designation or other payer guidance doesn’t tell you how to bill. For instance, some payers ask you to bill the procedure on one line with modifier 50, while others ask you to bill on two lines with modifier 50 on the second line, and others suggest two lines of service with modifiers LT and RT.

Bottom line: Learn the rules for your primary payers to avoid bilateral surgery claims denials.