Medicare Compliance & Reimbursement

Number '2' in column Z? Strike out modifiers 50, RT, LT as options.

Not sure if you can apply a modifier when your physician performs a bilateral procedure? Leaving the modifier off could cancel out additional compensation your physician deserves for the surgery.

Check out these sure-fire ways you can determine if a particular code allows a bilateral modifier.

Scenario: Your doctor performs a complete pelvic lymphadenectomy (38770, Pelvic lymphadenectomy...) on both sides, and you're not sure what modifier(s) to use. What should you do?

Before deciding between modifiers 50 (Bilateral procedure), LT (Left side), or RT (Right side) for a given claim, you should consult the Physician Fee Schedule database to see if a bilateral modifier is allowed (www.cms.hhs.gov/pfslookup).

Look at column Z of the spreadsheet, labeled "BILAT SURG." If you see a "1," you can use modifier 50 for that code and expect to receive 150 percent payment, says Denise Stanton, CPC, CCP-P, senior coding analyst at Beth Israel Deaconess Medical Center in Boston, Mass. "Medicare carriers for Part B services have published articles specifying their preference to report a bilateral service with a single line item with modifier 50 and 1 unit of service, whereas [some] non-Medicare payers prefer reporting bilateral services with two line items -- one with RT and 1 unit of service, and the second with LT and 1 unit of service," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver. Carriers may prefer modifiers RT/LT when your doctor performs a different procedure on each side, not the same procedure on each side.

Solution: When you find 38770 in the Physician Fee Schedule database, you notice a "1" in column Z. Therefore, you should report the procedure as 38770-50.

Avoid Bilateral Modifiers With '0'

If you see a "0" in column Z, you should not append modifier 50. "The '0' indicator means that the payment adjustment for bilateral indicator does not apply," Hammer says.

Scenario: A physician performs a bilateral laparoscopic ovarian cyst excision that does not involve the removal of any additional ovarian tissue.You should report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary ...). When you look up 58662 in the Physician Fee Schedule, you see a "0" bilateral indicator. That means you cannot use modifier 50.

Medicare rules will not allow you to use a bilateral modifier. In addition, no matter which approach the doctor uses, you should report the procedure code only once, no matter how many cysts the ob-gyn aspirates. "I always think of it this way: If the CPT code descriptor doesn't state 'each,' then it isn't asking me for quantity," says Carina Conti, CPC, senior coding analyst at New York Hospital Queens.

If you don't find a "1" or a "0" in column Z of the fee schedule database, you should avoid appending modifier 50, LT, or RT.

A "2" in column Z of the database indicates that payers will not apply the 150 percent rule to that particular procedure code. The relative value units (RVU) for such codes are already based on the procedure code representing one of the following:

• The code descriptor specifically states that the procedure is bilateral.

• The code descriptor states that the procedure may be performed either unilaterally or bilaterally.

• Physicians usually perform the procedure bilaterally. Also, if column Z includes a "9," the concept of bilateral surgery does not apply to that code. Therefore, you should never claim modifier 50 or modifiers LT/RT in combination for that procedure. Such procedures are relatively uncommon for an ob-gyn practice, but you would see this indicator for all lab codes, because they are nonsurgical services.

"An additional indicator, '3,' means the usual payment adjustment for bilateral procedures does not apply because these codes are typically radiology procedures or diagnostic tests, which are not subject to the special payment rules for other bilateral surgeries," says Hammer.