Neurology & Pain Management Coding Alert

Location modifiers increase specificity, but consult the fee schedule first

Modifiers -LT and -RT and modifier -50 provide similar functions - and you can easily confuse them - but they are not interchangeable. To aid in your selection of these modifiers, follow these three pointers.

1. Consult the Physician Fee Schedule Database

Before deciding on modifier -50 (Bilateral procedure) or modifiers -LT (Left side)/-RT (Right side), you should consult the CMS Physician Fee Schedule Database.
 
If a "1" appears in Column "T" of the fee schedule, modifier -50 is allowed for that particular code.
 
A "0" in Column "T" tells the physician and/or coder that modifier -50 is not allowed and, therefore, if the neurologist performs the procedure bilaterally, modifiers -LT and -RT are appropriate.
 
A "2" in Column "T" indicates that the code already specifies a bilateral procedure, so you should not attach a modifier to these codes or expect payment adjustments for a bilateral procedure.
 
Examples: The fee schedule database assigns a 1 indicator to column T for H-reflex studies 95934 (H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle) and 95936 (... record muscle other than gastrocnemius/soleus muscle).
 
This means that you may append modifier -50 if the neurologist provides a bilateral H-reflex study. You should report the procedure using one code as a single line item on the CMS-1500 claim form (in other words, 95934-50, not 95934, 95934-50).
 
In a second example, the fee schedule assigns a 2 indicator to column T for visual evoked potential 95930 (Visual evoked potential [VEP] testing central nervous system, checkerboard or flash). These means that the code already describes a bilateral procedure, and you should not append a modifier if the neurologist indicates she tested both the right and left eyes.
 
Tip: You can download the Physician Fee Schedule Database free from the CMS Web site www.cms.gov. Use the "search" function to find "2004 Physician Fee Schedule."
 
2. Apply -LT/-RT to Increase Unilateral Specificity

If the neurologist performs a procedure on one limb or paired organ, you can use modifiers -LT/-RT to make your claim more specific, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
Examples: If the patient has a suspected diagnosis of carpal tunnel syndrome (CTS, 354.0) in the left wrist, and the neurologist performs EMG on one extremity only (the left arm), you should submit 95860 (Needle electro-myography; one extremity with or without related paraspinal areas) with modifier -LT attached.
 
As a second example, when treating a patient for CTS, a neurologist may apply a splint to the affected wrist(s). You should report splint application using 29125 (Application of short arm splint [forearm to hand]; static) or 29126 (... dynamic) as appropriate, depending on whether the splint allows movement of the wrist.
 
Append the -LT or -RT modifiers, along with supporting documentation, to designate the location of the splint. If the neurologist applies splints on both wrists, report 2912x-LT and 2912x-RT (on two lines), Jandroep says.
 
3. Contact the Carrier

Ultimately, due to nation-wide inconsistencies, the best way to know whether modifiers -LT/-RT or -50 is appropriate is to contact your individual carriers.
 
Some payers will cite specific instances in which they prefer modifier -50 and others in which they recommend modifiers -LT/-RT. Other payers prefer modifiers -LT/-RT in all circumstances because they think these modifiers are more specific than modifier -50.
 
Get it in writing: Always be sure to get the payers' coding recommendations and payment guidelines in writing to protect yourself in the event of future audits or claims' reviews, says Thomas Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md.

Bonus Tip: Watch Your Payments

 Always check your explanation of benefits to be sure that payers are reimbursing your bilateral claims correctly.
 
Generally, payers should reimburse bilateral procedures, whether specified using modifiers -LT/-RT or modifier -50, at 150 percent of the Physician Fee Schedule relative value unit rate. For unilateral procedures specified with -LT/-RT, the payer will not adjust reimbursement.