Ob-Gyn Coding Alert

Not sure if you can apply a modifier when your ob-gyn performs a bilateral procedure (such as a lymphadenectomy)? Leaving the modifier off could cancel out additional compensation your physician deserves for the surgery.

Check out these sure-fire ways you can determine if a particular code allows a bilateral modifier -- or not.

Scenario: Your ob-gyn performs a complete pelvic lymphadenectomy (38770, Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]) on both sides, and you're not sure what modifier(s) to use. What should you do?

Before deciding between modifiers 50 (Bilateral procedure), LT (Left side), or RT (Right side) for a given claim, you should consult the Physician Fee Schedule database to see if a bilateral modifier is allowed (www.cms.hhs.gov/pfslookup/).

Look at column Z 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 Denise Stanton, CPC, CCP-P, senior coding analyst at Beth Israel Deaconess Medical Center in Boston, Mass.

"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. Think of it this way: Carriers may prefer modifiers RT/LT when your ob-gyn is performing a different procedure on each side, not the same procedure on each side.

Solution: When you find 38770 in the Physician Fee Schedule database, you notice a "1" in column Z. Therefore, you should report the procedure as 38770-50.

On the other hand, if you see a "0" in column Z, you should not append modifier 50. "The '0' indicator means that the payment adjustment for bilateral indicator does not apply," Hammer says.

Scenario: An ob-gyn performs a bilateral laparoscopic ovarian cyst excision that does not involve the removal of any additional ovarian tissue. You should report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method). When you look up 58662 in the Physician Fee Schedule, you see a "0" bilateral indicator. That means you cannot use modifier 50.

Medicare rules will not allow you to use a bilateral modifier. In addition, no matter which approach the obgyn uses, you should report the procedure code only once, no matter how many cysts the ob-gyn aspirates. "I always think of it this way: If the CPT code descriptor doesn't state 'each,' then it isn't asking me for quantity," says Carina Conti, CPC, senior coding analyst at New York Hospital Queens in Lake Success.

If you don't find a "1" or a "0" in column Z of the fee schedule database, you should avoid appending modifier 50, LT, or RT.

A "2" in column Z of the database indicates that payers will not apply the 150 percent rule to that particular procedure code. The relative value units (RVU) for such codes are already based on the procedure code representing 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: The ob-gyn aspirates ovarian cysts on both sides through an incision in the vaginal canal. That means you should report 58800 (Drainage of ovarian cyst[s], unilateral or bilateral [separate procedure]; vaginal approach).

Reality: You shouldn't include modifier 50 because the vaginal and abdominal approach codes include the nomenclature "unilateral or bilateral," says Marylou Masters, OGS, CPC, COBGC, ob-gyn coder/biller at UNT Health in Fort Worth, Texas.

Also, if column Z 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 for an ob-gyn practice, but you would see this indicator for all lab codes, because they are nonsurgical services.

"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.

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.