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.

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).

Before deciding on modifier -50 or modifiers -LT/-RT, consult the CMS Physician Fee Schedule. If a "1" appears in column "S" of the fee schedule, modifier -50 is allowed for that particular code. A "0" in column "S" tells the physician and/or coder that modifier -50 is not allowed and, therefore, if the procedure is performed bilaterally, modifiers -LT and -RT are appropriate. A "2" in column "S" indicates that the code already specifies a bilateral procedure and, therefore, no modifier or payment adjustment is necessary.

Ultimately, due to nationwide inconsistencies, the best way to know whether modifiers -LT/-RT or -50 is appropriate is to contact your individual carriers. Some payers will detail specific instances in which modifier -50 is preferred and others in which modifiers -LT/-RT are recommended. Other payers prefer modifiers -LT/-RT in all circumstances, for instance, because they feel the HCPCS modifiers are more specific. 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.

Generally, procedures performed bilaterally, whether specified using modifiers -LT/-RT or modifier -50, are reimbursed at 150 percent of the Physician Fee Schedule relative value unit rate. When billing, do not reduce your fee. Allow the payer to make the reduction. Payers should reimburse procedures performed unilaterally but appended with modifier -LT or -RT to denote a specific unilateral location at the standard rate. If the payer reduces the rate, be sure to appeal.

Some additional common neurology coding examples can provide guidance as to when a body-side modifier (-LT/-RT) or modifier -50 is appropriate.

When treating a patient for CTS, the neurologist may apply a splint to the affected wrist(s). Specifically, a splint that holds the wrist still while the patient sleeps often helps to relieve nighttime symptoms of tingling and numbness. Splint application is reported 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. Appending the -LT or -RT modifiers, along with supporting documentation, will designate the location of the splint, says Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern N.J. If splints must be applied bilaterally, report 2912x-LT and 2912x-RT.

If splinting fails to alleviate the patient's symptoms, the neurologist may administer steroid injections, including cortisone or other drugs, as a last resort before recommending surgery. Depending on the payer, applicable injection codes include 20605* (Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) or 90799 (Unlisted therapeutic, prophylactic or diagnostic injection).

When using injections to treat bilateral CTS, append modifiers -LT and -RT as appropriate, Hofbeck says. Bilateral injections should be reimbursed as independent procedures, she stresses, and are often provided at different visits, e.g., the left wrist is injected Tuesday and the patient returns Friday for an injection in the right wrist.

In other cases, modifier -50 is appropriate. For example, a patient complains of shooting pain and/or numbness in the right leg. The neurologist tests the patient with an H-reflex study. He or she first tests the left calf muscle to find the normal response for that patient, then checks for variation by testing the right calf. A delayed or nonexistent response on the affected side of the body may indicate nerve damage.

CPT descriptors for H-reflex codes 95934 and 95936 specify "muscle" rather than "muscles" and as such these are unilateral codes. Therefore, when the tests are performed on both sides of the body, the appropriate H-reflex study code should be reported with modifier -50 or the five-digit modifier 09950 attached, says Tiffany Z. Eggers, JD, MPA. In the above example, for instance, the neurologist would report 95934-50 as a single line item on the CMS 1500 claim form (i.e., not 95934, 95934-50) for his or her services.