Ophthalmology and Optometry Coding Alert

Just because the patient has two eyes doesn't mean modifier -50 applies

If you've been having difficulty determining when to use modifiers -50 (Bilateral procedure), -LT (Left side), and -RT (Right side), you're not alone. But our experts' advice - and the Physician fee schedule database - can help you select the appropriate modifier with confidence every time.

First step: Before you decide between modifier -50, -LT, and -RT for a given claim, you should consult the 2005 Physician Fee Schedule database, which is available on the CMS Web site at www.cms.hhs.gov/providers/pufdownload/rvudown.asp.

If you find a "1" in column "T" (labeled "Bilat Surg") of the fee schedule database, you can append modifier -50 to the code, says Carol Hunt, CPC, billing manager for the Robert C. Byrd Health Sciences Center Department of Ophthalmology at West Virginia University in Morgantown.

Example: An ophthalmologist performs a bilateral nasolacrimal duct probe (68810, Probing of nasolacrimal duct, with or without irrigation). When you find 68810 in the Physician fee schedule database, you'll notice a "1" in the "Bilat Surg" column, and you can therefore report 68810-50.

Depending on payer preference, you should either list the code once with the bilateral modifier appended (this is the method most Medicare carriers prefer) or list the procedure twice on two lines of the claim form (with the -LT appended to the code on the first line and -RT appended to the same code on the second line).

Most payers reimburse bilateral claims at 150 percent of the assigned fee schedule amount, Hunt says.

The code descriptors can often give you a hint regarding whether the procedure will garner more reimbursement if you append modifier -50, says Suzan Hvizdash, BSJ, CPC, physician education specialist at the University of Pittsburgh's department of surgery. If the descriptor indicates a bilateral procedure, modifier -50 won't bring you more money.

If you find a "0" in column "T" it means that modifier -50 is not allowed. You may report modifiers -LT or -RT, however, either in combination or singly, to make your claim more specific.

Example: Ocular photodynamic therapy (67221, Destruction of localized lesion of choroids [e.g., choroidal neovascularization]; photodynamic therapy [includes intravenous infusion]) contains a "0" in column T, meaning that you may not append modifier -50 to these procedures. This is because a specific add-on code - +67225 (... photodynamic therapy, second eye, at single session [list separately in addition to code for primary eye treatment]) -  describes the performance of this procedure on the other eye on the same day, says Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.

"So if the procedure is performed on both eyes, you would bill 67221-RT or -LT, and 67225 with the other eye modifier," Duran says. "Remember that since 67225 is an add-on code, you do not append the -51 modifier (Multiple procedures)."

If you find a "2" in column T it indicates that the code already specifies a bilateral procedure, so you should not append a modifier to denote a procedure's bilateral nature. Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: CPT code 92140 specifies, "Provocative tests for glaucoma, with interpretation and report, without tonography." The Physician Fee Schedule database assigns this code a "2" in column T. Therefore, if the surgeon performs glaucoma tests on both eyes, you should report a single unit of 92140, with no modifiers appended. The insurer will make no payment adjustment for a bilateral procedure.

If you find a "9" in column T, 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.

Example: The fitting of one aphakic lens, 92311 (Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens for aphakia, one eye), has a bilateral status of "9" and therefore may never have -50,   -RT or -LT appended to it on a claim form. To report fitting of aphakic lenses for both eyes, use code 92312 (... corneal lens for aphakia, both eyes).

Protect yourself: When dealing with non-Medicare payers, you should ask your insurers how they want you to report modifiers -50 and -LT/-RT. Not all private payers follow CMS guidelines. Some 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 think those modifiers are more specific.