Ophthalmology and Optometry Coding Alert

 Modifier 50 can bring your practice 150 percent of the fee schedule amount

You could be missing out on major reimbursement for bilateral claims if you're not clear about when to apply modifier 50 or the anatomical descriptors LT and RT. Let us walk you through the do's and don'ts of the Medicare Physician Fee Schedule database to help you select the appropriate bilateral or unilateral designation with confidence.

How to Use 50 Properly

Before you decide between modifier 50 (Bilateral procedure) and modifiers LT (Left side) or RT (Right side) for a given claim, you should consult the 2007 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. "An indicator 1 tells you the payer will reimburse you 150 percent for bilateral procedures -- 100 percent for the first eye and 50 percent for the second," says Nancy LaVergne, CPC, OCS, CAPPM, coder for Jackson Eye Associates in Missouri.
 
Example: Your physician removes lesions from both eyelids involving more than the skin. You should report eyelid lesion removal code 67840 (Excision of lesion of eyelid [except chalazion] without closure or with simple direct closure).
 
When you find this code in the fee schedule database, you'll notice a "1" in column T, and you can therefore report 67840 with modifier 50 attached to it because your physician performed a bilateral procedure.
 
Bonus: You can expect most payers to reimburse bilateral claims at 150 percent of the assigned fee schedule amount, says Lisa Center, certified professional coder with Mount Carmel Regional Medical Center in Pittsburgh, Kan.

LT and RT May Apply if Column T Lists a '0'

 A "0" in column T tells you that you cannot use modifier 50. You may report modifiers LT or RT, however, either in combination or singly, to make your claim more specific. CPT added the anatomic-specific modifiers RT and LT "to streamline the claims processing system, to allow for automated payment without having to request additional documentation to rule out duplicate or other inappropriate billing," according to the January 2000 CPT Assistant.

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

While a "1" in column T allows you to append modifier 50, a "0" indicates that bilateral adjustment does not apply, either because of physiology/anatomy or because the code is unilateral and there is a different code for the bilateral procedure, coding experts say.
 
A "2" in column T of the database indicates that the code already specifies a bilateral procedure, says Melissa Woods, CPC, coder and biller with Advanced Eye Care in Alexandria, Va., so you should not append a modifier to denote a procedure's bilateral nature.
 
Tip: Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.
 
Example: Your ophthalmologist performs a corneal topography on each eye during the same session. If you refer to the 2007 Fee Schedule, CMS designates 92025 (Computerized corneal topography, unilateral or bilateral, with interpretation and report) with a "0". Therefore, you should report this procedure with 92025, but you should not append modifier 50.
 
A "3" in column T of the database indicates that the code is not subject to the bilateral surgery adjustment and is paid at 100 percent for each side when you report the code with modifier 50 or LT/RT.

Seek Advice From Private Payers in Writing

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 insurers 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 than modifier 50.
 
Even when requiring modifier 50, some payers have different ways that they want you to report the services. Some carriers might prefer you to report your procedure code using two line items, appending modifier 50 to the second code (i.e., 67840, 67840-50). Other carriers might want the code reported only once, with modifier 50 appended (i.e., 67840-50).
 
Protect yourself: Always be sure to get the payers' coding recommendations and payment guidelines in writing in the event of audits or claim reviews, coding experts say.
 
In addition, "You should never settle for an mount that you feel is paid incorrectly. Fight for your reimbursement -- appeal, and appeal again," LaVergne says.