Neurosurgery Coding Alert

Gain reimbursement for bilateral procedures with the correct modifier

When a neurosurgeon performs a bilateral procedure such as a laminotomy, adding the correct modifier is key to showing the payer that the physician deserves additional compensation for the surgery. With the aid of Medicare's Physician Fee Schedule, you can be sure you-re getting the appropriate reimbursement.

Refer to the Fee Schedule for Guidance

Before deciding between modifiers 50 (Bilateral procedure) LT (Left side)/ RT (Right side) for a given claim, you should consult the 2006 Physician Fee Schedule database to see if appending a bilateral modifier is even allowable.
 
Look at column -T- of the spreadsheet, labeled -BILAT SURG.- If you see a -1,- you can use modifier 50 for that particular code and expect to receive 150 percent payment, says Barbara E. Oviatt, CPC, CCS-P, coding supervisor at Martin Memorial Medical Group in Stuart, Fla.
 
Here's how: Submit your claim with the code listed twice, once with modifier 50 and once without, and put modifier RT on one and modifier LT on the other. The payer should then process your claim and pay the neurosurgeon a total of 150 percent of the normal payment. But be sure to do this only with those few payers that process claims this way, because those that follow Medicare processing may pay you 150 percent on the one charge and 100 percent on the other.
 
-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 Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver.
 
Example: Your neurosurgeon performs a bilateral lumbar laminotomy procedure (63030, Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]). When you find this code in the Physician Fee Schedule database, you notice a -1- in column T, and therefore you should report the procedure as 63030-50.

Avoid Bilateral Modifiers With -0- Indicator

If you see a -0- in column T, you should not append modifier 50. -The -0- indicator means that the payment adjustment for bilateral indicator does not apply,- Hammer says.
 
Tip: You can use modifiers RT and LT for purely informational purposes when the physician does not perform services bilaterally, Hammer says. -For instance, a transforaminal epidural injection of the right L5 nerve could be coded as 64483-RT. This merely informs the payer that the transforaminal epidural was performed on the right side of the lumbar spine.- 
 
Example: A neurosurgeon performs a bilateral frontal craniotomy to evacuate subdural hematomas. You should not use modifier 50 (Bilateral procedure) with 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) because the Medicare Physician Fee Schedule database shows a -0- bilateral indicator for 61312.
 
Because the surgeon performed the frontal craniotomy at two locations on either side of the skull, you should report 61312 and 61312-59 (Distinct procedural service).
 
Append modifier 59 on the second unit of 61312 to indicate that the physician performed the second craniectomy at a separate anatomic location. Then, to further differentiate the craniectomies, you may also append modifiers LT and RT.

Identify Inherently Bilateral Codes

If you don't find a -1- or a -0- in column T of the fee schedule database, you should avoid appending 50, LT and RT.
 
A -2- in column T of the database indicates that payers will not apply the 150 percent rule to that particular procedure code, Oviatt says. The relative value units (RVU) for such codes are already based on the fact that the procedure code represents 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.

Example: Some spinal procedures, such as laminectomies (63001-63017, 63045-63048), qualify as -inherently- unilateral or bilateral surgeries, so you should not append modifier 50 or LT/RT in combination to report procedures on both the left and right side at the same spinal level.
 
For example, the neurosurgeon performs a bilateral laminectomy at a single cervical segment. You should report 63045 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; cervical) with no modifiers appended.
 
But if the surgeon performs a unilateral laminectomy at two cervical levels, you may report 63045 as well as +63048 (... each additional segment, cervical, thoracic or lumbar [list separately in addition to code for primary procedure]). 
 
Note: If column T 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 in a neurosurgery practice.
 
-There is an additional indicator -3- that 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,- Hammer says.
 
Protect yourself: Private-payer rules can vary greatly from Medicare guidelines when it comes to how you should use the bilateral modifiers. Always be sure to get the payers- coding recommendations and payment guidelines in writing to protect yourself in the event of audits or claim reviews.
 
Bonus: You may download the current Physician Fee Schedule database free from the CMS Web site at www.cms.hhs.gov/apps/pfslookup/step0.asp. Stay tuned to future issues of Neurosurgery Coding Alert for articles on how to use and make the most of the Medicare Physician Fee Schedule.