Neurosurgery Coding Alert

Realize $430 more for bilateral laminotomy with the correct modifier

You're not alone if you find it difficult to distinguish among modifiers -LT and -RT and modifier -50. Fortunately, with the aid of the Physician Fee Schedule database and our experts' advice, you can select an appropriate modifier with confidence.

Turn to the Fee Schedule for Guidance

Before deciding between modifier -50 (Bilateral procedure) and modifiers -LT (Left side) or -RT (Right side) for a given claim, you should consult the 2004 Physician Fee Schedule database.

If you find a "1" in column "T" (labeled "BILAT SURG") of the fee schedule database, you may use modifier -50 for that particular code.

Example: The surgeon performs a bilateral lumbar laminotomy (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 report the procedure 63030-50. Because most payers reimburse bilateral claims at 150 percent of the assigned fee schedule amount, you can expect an additional $430 for this procedure (for a total payment of $1,290, based on national average payment using 2004 fee schedule figures).

A "0" in column T tells you that modifier -50 is not allowed. You may report modifiers -LT or -RT, however, either in combination or singly, to enhance the specificity of your claim.

Example: Tendon sheath and trigger point injections (20550-20553) contain a "0" in column T, meaning that you may not append modifier -50 to these procedures. But if the surgeon provides several injections to the right wrist and several more to the left wrist, you can report the injections using 20550-RT (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) and 20550-LT, says Allison Waxler, practice management policy analyst at the American Academy of Physical Medicine and Rehabilitation.

This is a more effective method than simply reporting 20550 x 2 because payers might reject the second unit as a redundant (repeat) procedure. By specifying -RT and -LT, you clearly demonstrate injections to two different anatomic locations.
 
Note: To further demonstrate the separate nature of the injections sites, you should also append modifier -59 (Distinct procedural service) to the second unit of 20550.

Don't Expect to Use -50 or -LT/-RT With All Codes

If you don't find a "1" or a "0" in column T of the fee schedule database, you should append neither modifier -50 nor modifiers -LT/-RT.

A "2" in column T of the database indicates that the code already specifies a bilateral procedure and, therefore, you should not append a modifier to denote a bilateral procedure. Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: CPT code 61253 specifies, "Burr hole(s) or trephine, infratentorial, unilateral or bilateral." Further, the Physician Fee Schedule database assigns this code a "2" in column T. Therefore, if the surgeon drills burr holes on both sides of the skull, you should report a single unit of 61253, with no modifiers appended. The insurer will make no payment adjustment for a bilateral procedure.

Some spinal procedures, such as laminectomy (63001-63017, 63045-63048), also 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, says Tiffany Schmidt, JD, policy director for the American Association of Electrodiagnostic Medicine.

For example, the surgeon performs bilateral laminectomy at a single cervical segment. You should report this as 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 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]).

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.

Example: The Physician Fee Schedule database assigns a "9" to 22841 (Internal spinal fixation by wiring of spinous processes). A surgeon providing this procedure would report a single unit of 22841, regardless of the location of the processes he wires.

Seek Advice From Private Payers (in Writing)

When dealing with non-Medicare payers, you should seek the insurer's advice on the correct use of modifiers -50 and -LT/-RT. Not all private payers follow CMS guidelines: Some payers will specify when they prefer modifier -50 and when they require modifiers -LT/-RT. Other payers prefer modifiers -LT/-RT in all circumstances because they feel those modifiers are more specific than modifier -50.

Protect yourself: 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, says Thomas Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md.

Note: You may download the current Physician Fee Schedule database free from the CMS Web site (www.cms.gov). Use the "search" function at the top left of the CMS home page to locate "2004 Physician Fee Schedule."