General Surgery Coding Alert

Decode LT/RT, 50 modifier choices.

That’s because the procedures themselves are different — some are inherently bilateral and some are not — and because payer rules for billing bilateral services are all over the map. If you make a billing mistake, you could be leaving your surgeon’s well-deserved pay on the table. 

Look at the following tips to make sure that your bilateral claims are always a success.

Tip 1: Learn Your Bilateral Coding Choices

Depending on the payer, when your surgeon performs a bilateral procedure, you may need to attach a single modifier to a single code, bill the code twice on separate line items, or use anatomic site modifiers to identify where the procedure was performed. Which method you chose often depends on the payer.

The basics: Some procedures are inherently unilateral, so if you perform them bilaterally, you can collect extra pay for them, typically by appending modifier 50 (Bilateral procedure), or by indicating the site the surgeon addressed with modifiers LT (Left side) and RT (Right side). 

Caution: If the procedure descriptor indicates that the code represents a bilateral procedure, you cannot use bilateral modifiers on it because it is already considered bilateral in nature, says Gaye Pratt, RMM, RMC, business office manager for Vincent P. Miraglia, MD, in Stuart, Fla. 

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

Tip 2: Check Medicare Policies

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.
• 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.” 

Caveat: Although all Medicare payers defer to the fee schedule designation to determine when it’s appropriate to submit bilateral claims, they don’t all agree on how you should do it.  

Here’s a peek at a few Medicare payer policies: 

Noridian: Append modifier 50 to the procedure code, with a “1” in the units field. “Billing two lines with LT and RT modifiers may cause the claim to deny,” states Noridian on its Website. 

WPS: According to their Website, WPS gives you several options : “The provider may submit the charges using the modifier LT and RT on two lines of service. The provider may submit the charges using one line of service including both the LT and RT on the same line. The provider may also choose to submit the surgery procedure code with one line of service using modifier 50.”

Watch out: To complicate the bilateral billing matter even further, CMS maintains different rules if you code for an ambulatory surgical center (ASC’s) services. In a Q&A on the CMS Web site, the agency notes that for ASCs, “Bilateral procedures should be reported as a single unit on two separate lines or with ‘2’ in the units field on one line.” CMS won’t recognize modifier 50 for ASC payment, according to CMS’s advice (available at https://questions.cms.gov/faq.php?id=5005&faqId=2315).

Tip 3: Focus on Private Payer Policies, Too

Beyond Medicare, the bilateral billing rules vary even more.

For example, UnitedHealthcare’s bilateral policy states “The procedure should be billed on one line with a modifier 50 and one unit with the full charge for both procedures.” 

But Blue Cross Blue Shield of Alabama states “When billing for bilateral surgery, the procedure code should be listed on two lines with modifier 50 (bilateral procedure) placed to the right of the procedure code on the second line.” 

Bottom line: You must understand your payer’s policy when reporting bilateral services. Experts suggest creating your own “cheat sheet” that lists your payers and their bilateral billing policies.

Tip 4: Beware Unilateral Bilateral Procedure

Remember the caution at the start of this article — you can’t use bilateral modifiers for a procedure that is inherently bilateral. So what happens if your surgeon performs one of those procedures unilaterally, for some reason?

For instance: The surgeon performed laparoscopic total pelvic lymph node dissection (38571, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy), but was able to remove lymph nodes only from the left side. 

Do this: In that case, you should add modifier 52 (Reduced services) to 38571. “Because this code is inherently bilateral, when the surgeon completes only one side, modifier 52 indicates that the surgeon did less work than the code description and should not receive the full payment amount,” explains Jan Rasmussen, PCS, CPC, ACS-OB, ACS-GI, president of Professional Coding Solutions, in Eau Claire, Wis.