Ob-Gyn Coding Alert

Varied policies aren’t just limited to private payers. 

There are many procedures that your ob-gyn may perform on both sides of the patient’s body, and sometimes it seems that there are just as many rules about how to report those bilateral services. Different payers want you to report bilateral services in different ways. Review the following rules to help make the process easier and improve your bilateral claims success.

Know the Options At Hand

Depending on the payer, when your ob-gyn performs a bilateral procedure, you may need to attach a single modifier to a single code, bill the code twice on separate line items, or use anatomic site modifiers to identify where the procedure was performed. Which method you choose depends on the payer to whom you are submitting the claim. 

The basics: Some procedures are inherently unilateral, so if you perform them bilaterally, you can collect extra reimbursement for them, typically by appending modifier 50 (Bilateral procedure), or by indicating the site you addressed with modifiers LT (Left side) and RT (Right side). For Medicare claims, bilateral billing is only appropriate when the bilateral surgery indicator for a particular code is “1” or “3,” according to the Medicare Physician Fee Schedule.

Remember: If the procedure descriptor indicates that the code represents a bilateral procedure, you cannot use bilateral modifiers on it because it is already considered bilateral in nature, says Gaye Pratt, RMM, RMC, business office manager for Vincent P. Miraglia, MD, in Stuart, Fla. “If it indicates it is unilateral you can. For example, a tubal ligation is bilateral in nature, therefore you cannot bill it bilaterally. On the other hand, a fimbrioplasty is considered unilateral and can be billed bilaterally successfully.”

Don’t Assume All MACs Have the Same Policy

Even different Medicare payers have their own preferences on how you should submit bilateral claims. Take a look at the following three policies from three Part B MACs.

Noridian: For instance, Noridian Medicare requests that you append modifier 50 to the procedure code, with a “1” in the units field. “We (Noridian) will process claims for bilateral surgeries according to the presence of the 50 modifier on the CMS-1500 claim form, or its electronic submission, or of the same code on separate lines, one line with LT modifier and the other with the RT modifier,” the Part B MAC states on its website (https://med.noridianmedicare.com/web/jeb/specialties/surgery/bilateral-surgeries). “We recommend such surgeries be billed on one line with the 50 modifier. Billing two lines with LT and RT modifiers may cause the claim to deny.”

Palmetto GBA: If the bilateral indicator for a procedure is “3,” Palmetto GBA indicates that you could report your procedure on a single line item with modifier 50 appended and “2” in the units field, or you have the alternate option of submitting the surgery on two lines, one with modifier RT appended, and one line with modifier LT appended.

WPS: In addition, even within particular MACs, the rules can vary. For instance, the Web site for WPS Medicare (http://www.wpsmedicare.com/j8macpartb/claims/submission/billing-processing-bilateral-surgical-procedures.shtml) notes, “Providers have a choice when billing for a surgery performed bilaterally. The provider may submit the charges using the modifier LT and RT on two lines of service. The provider may submit the charges using one line of service including both the LT and RT on the same line. The provider may also choose to submit the surgery procedure code with one line of service using modifier 50.”

Focus on Private Payer Policies, Too

Even beyond Medicare, the bilateral billing rules vary dramatically. 

“Some insurance companies — Cigna comes to mind right away — don’t follow the same guidelines,” Pratt says. “I am rarely successful challenging them on it, but I still try.”

For example, UnitedHealthcare’s bilateral policy (https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesHtml/ReimbursementPolicies/Bilateral_v2014A.pdf) states “The procedure should be billed on one line with a modifier 50 and one unit with the full charge for both procedures.” 

However, Blue Cross Blue Shield of Alabama’s policy: (https://www.bcbsal.org/providers/manuals/providermanual/modifiers.cfm ) states “When billing for bilateral surgery, the procedure code should be listed on two lines with modifier 50 (bilateral procedure) placed to the right of the procedure code on the second line.”

Bottom line: You must understand your payer’s policy when reporting bilateral services. Experts suggest creating your own “cheat sheet” that lists your payers and their bilateral billingpolicies. 

Watch out: To complicate the bilateral billing matter even further, CMS maintains different rules if you code for an ambulatory surgical center (ASC’s) services. In a Q&A on the CMS Web site, the agency notes that for ASCs, “Bilateral procedures should be reported as a single unit on two separate lines or with ‘2’ in the units field on one line.” CMS won’t recognize modifier 50 for ASC payment, according to CMS’s advice (available at https://questions.cms.gov/faq.php?id=5005&faqId=2315).