Neurology & Pain Management Coding Alert

Rejoice in 150-percent payment for correct modifier 50 use.

When your neurologist performs a procedure, such as Botox injections, on mirrored locations on a patient's body, knowing how and when to append modifier 50 (Bilateral procedure) can add a significant boost to your bottom line.

Good news: Appending modifier 50 means you should expect to see 150 percent of the normal allowed reimbursement for the procedure. Learn what the experts suggest for getting the reimbursement you could have coming when your neurologist performs a bilateral procedure.

Check Physician Fee Schedule First

To find out if you can report any CPT code as bilateral or unilateral, check the Medicare physician fee schedule. You can find the bilateral indicator in column "Z" ("Bilat Surg") of the spreadsheet.

This indicator tells whether the code you are using can be reported bilaterally. A "1" means you're free to append modifier 50 when appropriate.

For example, you will find a "1" indicator in the bilateral surgery column for 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve...) and 64614 (...extremity[s] and/or trunk muscle[s]...).

Zero in: If you find a status indicator of "0" in the bilateral surgery column, you can never report that procedure code as bilateral.

Two easy: Medicare assigns indicator "2" to codes that already specify a bilateral procedure, so you do not need to append a modifier to show that you performed any of these on both sides of the body. Often, such codes will also specify "unilateral or bilateral" in their individual CPT descriptors.

"Many codes now are already 'bilateral,' which makes coding much easier in my opinion," says Lynn McCormick, CPC, with Nevada Neurosciences in Las Vegas. "It leaves less room for an insurance company to make payment errors."

Example: Cervical chemodenervation (64613,Chemodenervation of muscle[s]; neck muscle[s] (e.g., forspasmodic torticollis, spasmodic dysphonia]) is one such procedure with the bilateral component built in. "One of the biggest bilateral breakthroughs for neurology is that Medicare now reimburses us for bilateral cervical chemodenervation at 150 percent," says Megan Murdock, accounts coordinator with Neurology Associates Inc. in St. Louis.

Important: The bilateral procedures must be performed during the same operative session. Anatomic Sites Offer Modifier Usage Clues

Some payers still prefer that you use modifiers RT (Right side) and LT (Left side) for procedures, such as chemodenervation, when they involve a unilateral injection. You would code thesingle right-side injection as 64614-RT, for example.

Be careful: For injections to the facial area, you should only report bilateral administration for separate sides of the face or both right and left eye areas. Separate injection sites on the same side of the face constitute a single, unilateral chemodenervation procedure.

Just because a procedure is performed on both sides of the body does not automatically mean you'll use modifier 50. There may be instances when appended modifiers LT or RT are more appropriate.

You might use LT and RT when indicating that only one side of the body was done for what is normally a bilateral procedure, says Angeliki Medrano, CPC, a neurology coder in Boston.

Hint: When it comes to bilateral modifiers, "it seems that more and more payers are not recognizing them and specifically asking coders not to use them," McCormick says. You should check your individual payers' guidelines first, however.

Final reminder: Regardless of your modifier choice, don't forget to link the proper ICD-9 codes each time to support medical necessity for the injections. Also, if your practice supplies the medication, include the proper J code (such as J0586, Injection, abobotulinumtoxinA, 5 units) on the claim for the total amount of botulinum toxin injected.