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General Surgery Coding Alert

Reader Question:

Medicare, Private Carriers Differ on Modifier -50

Published on Wed Aug 01, 2001

Question: When using modifier -50 for a bilateral procedure, should we list the procedure code twice with -50 appended to the code on the first line, or should we only use the procedure code once, with -50 appended? How much should we charge?

Michigan Subscriber
 
Answer: The answer depends on the payer, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J.
 
For example, most Medicare carriers want to see one line only with modifier -50 (bilateral procedure) appended to the appropriate CPT code. But because many private payers cannot process one-line claims with modifier -50 correctly, two lines should be used, with the modifier appended on the second line. For example, a bilateral initial inguinal hernia repair should be reported to a private carrier as follows:
 
49505
49505-50

or

49505-LT
49505-RT
 
Note: Many carriers also accept modifiers -LT (left side) and -RT (right side) in place of modifier -50.
 
When billing a local Medicare carrier for the same repair, only one line should be used, as follows:
 
49505-50

or

49505-LT
49505-RT
 
Modifier -50 claims usually reimburse 150 percent of the allowable fee for the procedure, and this amount should be billed to Medicare carriers.
 
When billing private payers on two lines, do not cut the fee for the second procedure. "If you cut the fee for the second procedure, some carriers may incorrectly assume that the second line is for a duplicate procedure and cut the fee even more," Cobuzzi says. She adds that coders should check the carrier's explanation of benefits to make sure payment has not been reduced inappropriately.

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