Internal Medicine Coding Alert

Hint: Read the CPT^® code descriptors carefully.

At times, a provider will need to perform the same procedure  on  both  sides  of  the  patient’s  body.

When this occurs, you might be able to report the procedure code with modifier 50 (Bilateral procedure) appended — but not always, say those in the know.

The rundown: Code correctly with modifier 50, and you can expect 150 percent payment for the procedure(s) based on the Medicare Physician Fee Schedule. Append the  modifier  incorrectly,  however,  and  it  could  spell  trouble in the form of a denial.

Got questions on when to use modifier 50? Check out this expert input for the answers you need.

Report Identical Procedures with Modifier 50

Two of the easiest ways to find out if an encounter meets modifier 50 criteria are checking procedure notes and reading the CPT® code descriptors.

“Apply  modifier  50  whenever  the  exact  same  procedure,  the  same  exact  CPT^® code,  is  performed  on  bilateral  structures  of  the  body,”  says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit  manager  with  PeaceHealth  in  Vancouver,  Wash.

Example: Let’s  say  a  patient  reports  with  suspected  foreign  bodies  (FBs)  in  both  ears.  The  internist  finds  and  removes  a  small  pebble  from  both  external  ear  canals  without  general  anesthesia.  You  would  report  these  services  as  69200  (Removal foreign body from external auditory canal; without general anesthesia)  with  modifier  50  appended  to  show  that  the  physician  performed  the  procedure  on  both  ears.

Remember: Non-Medicare payers vary as to how they pay for modifier 50, and you cannot assume that they will apply the same rules as Medicare. If you are unsure of a private payer’s stance on modifier 50, check with a payer representative before filing a bilateral claim.

Read Descriptors Closely

“The  50  modifier  is  necessary  when  the  procedure  is  being  done  on  both  sides  of  the  body,  but  doesn’t  already  have  the  [bilateral]  verbiage  in  the  description  of  the  code,”  explains Suzan Hauptman, CPC, CEMC, CEDC, senior principal  of  ACE  Med  group  in  Pittsburgh,  Pa.

To  Hauptman’s  point,  there  are  often  clues  in  the  CPT^® code descriptors that indicate whether a procedure is unilateral or bilateral. If you pay attention to the descriptors, you’ll have the first hint on whether you’ll need modifier 50 for the claim.

Example: A patient reports to the physician with a nosebleed in both nostrils. The physician stops the bleeding in both nostrils with limited cautery and packing. On the claim, you’d report 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) with modifier 50 appended to show that the procedure was bilateral.

Big clue: Beneath  the  30901  descriptor  in  CPT^® 2017, there  is  a  parenthetical  note  stating  “To  report  bilateral  procedure,  use  30901  with  modifier  50.”  This  verbiage  should  alert  you  to  modifier  50  opportunities  if  the  provider  performs  a  procedure  on  both  sides  of  a  patient’s  body.

Know When Modifier 50 Won’t Work

Keep in mind that there are some codes that do not allow the use of the 50 modifier to reflect performance of the exact same CPT® code on bilateral anatomy.

Example: The code 30300 (Removal foreign body, intranasal; office type procedure) does not recognize the 50 modifier even when the provider performs the procedure bilaterally. So, if the provider removes a foreign body from each of a patient’s nostrils, you cannot report 30300-50, according to rules in the Medicare Physician Fee Schedule.

The only option for this encounter is to report 30300 and 30300 with modifier 59 (Distinct procedural service), or the appropriate X modifier, appended to indicate that the provider removed two different foreign bodies from two  different  sites.  You  still  might  not  get  paid  for  both  procedure codes, however.

Remember, Some Codes Are Already Bilateral

Coders beware: Not all bilateral services are ripe for coding with modifier 50. At times, physicians will perform a procedure whose description refers to “unilateral  or  bilateral”  or  “one  or  two  sides.”  This  means  that the value of the codes is the same whether they are performed on one or both sides of the body, and you’ll only submit a single code. The difference is in the code descriptors, Bucknam explains.

“Note some procedures have separate codes for unilateral or bilateral, depending on which is done,” says Bucknam. For these encounters, it would be inappropriate to use modifier 50 on the unilateral code instead of choosing the bilateral code, she adds.

Resource: You  can  also  check  the  indicator  in  the  “BILAT”  column  of  the  Medicare  Physician  Fee  Schedule.  “Use  modifier  50  with  CPT®  codes  that  have  indicators  1  or  3.  Codes  with  indicators  0,  2,  and  9  should  never  be  billed  with  modifier  50,”  Bucknam  says.  You  can  find  the  fee  schedule  at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.

LT/RT or 50? Know Your Payer

Modifier 50 is not the only modifier you might use on a  “two-sided”  claim.  Coders  use  modifiers  LT  (Left side) and RT (Right side) most often when coding for a procedure on one side of the body which, at some point, might be performed on the other side, says Hauptman.

Caveat:  Some  payers  prefer  you  use  RT  and  LT  instead  of 50, including some Medicare payers. The most common methods of reporting bilateral procedures are:

• One unit of service with modifier 50 on one line. (This is how Medicare instructs providers to submit claims for bilateral services.)
• One  unit  of  service  on  each  of  two  lines  with  modifier  RT  on  one  line  and  modifier  LT  on  the  second  line.
• One unit of service on each of two lines with modifier  RT  on  one  line  and  modifiers  50/LT  on  the  second line.
• Two  units  of  service  on  one  line  with  the  modifier  50.
• Two  units  of  service  on  one  line  with  no  modifier.

“Medicare typically wants the service reported on one line with modifier 50 and 1 unit, but other payers have other rules and you can lose a lot of money if you don’t follow those rules,” says Bucknam.

If you are unsure about a payer’s bilateral procedure coding policy, contact a representative before filing a bilateral claim.

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