Neurology & Pain Management Coding Alert

Many common neurological procedures, such as EMG testing, H-reflex studies and Botox injections, may be administered either unilaterally or bilaterally, as circumstances warrant. To demonstrate an appropriate level of specificity and ensure timely payment, neurologists and neurology coders must understand how to use modifiers -LT (Left side) and -RT (Right side) and -50 (Bilateral procedure) appropriately. Modifier Application Can Be Confusing Modifiers -LT and -RT are HCPCS level II national modifiers originally developed for those carriers whose automated billing systems do not recognize CPT modifiers (such as modifier -50). Modifiers -LT and -RT were designed not simply to augment modifier -50, but in some cases actually for use in place of modifier -50. To date, however, Medicare and private payers have not developed a uniform agreement on how these modifiers should be applied leaving coders to sort through the resulting confusion. In some cases, the decision as to which modifier is appropriate is obvious. For instance, if a diagnostic test such as an electromyography (EMG) is provided on one limb only, as when testing for carpal tunnel syndrome (CTS), either modifier -LT or modifier -RT may be added to indicate a greater level of specificity. For example, if the patient has CTS in the left wrist, and the neurologists performs EMG on that wrist, he or she should report 95860 (Needle electromyography, one extremity with or without related paraspinal areas) with modifier -LT attached and a diagnosis of 354.0 (Carpal tunnel syndrome).

Note: Bilateral EMGs are reported 95861 ( two extremities ), not 95860-LT, 95860-RT. Do not attach modifier -50 to 95861: The code descriptor already specifies "two extremities." In other cases, such as those that involve truly "bilateral" procedures, the decision is not so obvious. Generally, modifier -50 is appropriate to report bilateral procedures performed during the same patient encounter or operative session and is restricted to surgical procedures (10040-69990) and some diagnostic procedures (e.g., H-reflex studies, 95934 and 95936) when performed bilaterally. Furthermore, you should append modifier -50 only if the CPT code descriptor does not already include the term "bilateral." And, a bilateral procedure with modifier -50 appended should be reported as one line item on the CMS 1500 form (see example, below). Modifiers -LT and -RT, meanwhile, are used to report a procedure performed on one side of paired organs (e.g., ears, eyes, kidneys) or, sometimes (as is usually the case in neurology), paired extremities (e.g., arms and legs). And modifiers -LT and -RT are appropriate if a procedure is performed on only one side (as described in the example above). Fee Schedule Can Provide Guidance Before deciding on modifier -50 or modifiers -LT/-RT, consult the CMS Physician Fee Schedule. If a "1" appears in column [...]