Neurosurgery Coding Alert

Question: We are reporting bilateral procedures for injection codes 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) and 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed). What is the best way to report the bilateral procedures? Can we append modifier 50 or do we submit the LT and RT codes?

Oklahoma Subscriber

Answer: You can adopt either of the following to submit your bilateral procedures claims:

1. Report the procedure code on one line, write "1" in the units field, and append modifier 50 (Bilateral procedure).

2. Report the procedure code on one line, write "2" in the units field, and use the LT (Left side) and RT (Right side) modifiers.

3. Report the procedure code on two lines, write "1" in the units field, and use modifier LT on one line and RT on the other.

Confirm bilateral procedure: Make sure that the procedure that you are reporting meets the definition of bilaterality, i.e. your physician performed the procedure at a mirror-image anatomic site. Also, do not forget to check your payer specifications for bilateral procedures. Some payers may want you to report a bilateral procedure on two lines of service and append modifier 50 to the second line of service. You can escape incomplete claims by verifying what your payer wants in specific.

Medicare: According to Medicare, modifier 50 is only appropriate when the bilateral surgery indicator is "1" or "3." Medicare allows covered services at 150 percent of the Medicare Fee Schedule for the service codes that have an indicator of "1" when the service is provided bilaterally.

For these situations, report the procedure code once and append modifier 50 with one unit of service. However, do not include modifier 50 when your physician performs the service on different areas of same side of the body.

Remember: You do not append modifier 50 when the CPT® descriptor designates the procedure as "bilateral," for example, code 64615 (Chemodenervation of muscle[s]; muscle[s] innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral [e.g., for chronic migraine]).