Ophthalmology and Optometry Coding Alert

Remember to review the fine print, as payer policies may differ.

Even though every coder frequently uses modifiers on their claims, sometimes the rules surrounding when to indicate the side of the body affected and which modifier to append — LT (Left side), RT (Right side), or 50 (Bilateral procedure) — can get a bit murky.

Payer guidance regarding these laterality modifiers is all over the map, so we went to industry pros to set the record straight. Follow these five steps to refine your modifier 50, LT, and RT application skills, and take note of some key pointers from payers regarding which modifiers they want to see on your claims.

First, Evaluate Whether a Modifier Is Needed

There are some instances where the code has laterality built in. So, before you apply any kind of modifier, make sure you read the CPT^® code descriptor very, very carefully. “If the descriptor includes the word ‘bilateral,’ you should probably not append a laterality modifier,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. So, for example, adding a laterality modifier to 99177 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis) would not only be unnecessary, it would also be incorrect, as the descriptor specifies the code applies to the screening of one or both eyes.

Second, Verify When You Should Apply -50

A procedure that is not designated as bilateral but can be performed on an anatomic structure that is symmetrical (i.e., nose or cheeks) or paired (i.e., eyes or limbs) will need modifier 50 if it is performed on both sides of the body. So, you would append -50 to 67800 (Excision of chalazion; single) if an ophthalmologist removes a chalazion — a small nodule that results from a blockage of an oil gland and ongoing inflammation — from both the left and right eyelids.

Payer alert 1: Novitas Solutions tells you not to append modifier 50 “to procedures for midline organs such as the bladder, uterus, esophagus, or nasal septum” or “when performed on different areas of same side of body,” the Part A/B Medicare Administrative Contractor (MAC) for Jurisdictions J and L says in its online guidance (www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00144531). This rule applies to all Medicare Part B payers.

Third, Know the Dos and Don’ts of Appending LT/RT

Essentially, you should apply the same thought process to using an LT/RT modifier as you do for modifier 50. Or, to put it another way, “modifiers -LT and -RT should be used whenever a procedure is performed on only one side … [of] paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries,” according to the Medicare Claims Processing Manual (www.cms.gov/files/document/chapter-4-part-b-hospital-including-inpatient-hospital-part-b-and-opps-0).

But be careful, warns Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/ coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. “The most common mistake I see is attempting to add an additional RT or LT modifier when using modifier 50. Modifier 50 already indicates that the service was bilateral, so the use of these two additional modifiers would be incorrect,” she advises. So, in the 67800 example, you would not report bilateral chalazion removal with 67800-50-LT, 67800-50-RT. But you would be correct in using either -RT or -LT if the ophthalmologist removed a chalazion from only one eyelid.

Payer alert 2: Emblem Health follows this LT/RT policy: “Do not bill modifiers LT and RT on the same service line when using modifier 50 to indicate a bilaterally performed procedure. Modifier LT or RT should be used to identify which of the paired organs was operated on.” In other words, “do not use modifier 50 when removing a lesion on the right arm and a lesion on the left arm. Use the RT and LT modifiers,” the private payer cautions (www.emblemhealth.com/providers/claims-corner/coding/correct-usage-of-modifier-50-and-modifiers-lt-and-rt-for-bilater).

Fourth, Double-Check the Payer’s Bilateral Guidelines

Even though CPT^® and Medicare instruct you to use modifier 50 on one line of your claim when the modifier applies, some private payers do not follow these guidelines. Consequently, you should check with your payers, as some may want you to report codes with bilateral modifiers on two lines with -50 on the second line. Some Medicaid payers have applied this rule. Others may prefer two lines with the RT modifier on one line and the LT modifier on the other when appropriate.

Payer alert 3: Palmetto GBA requires you to “submit the surgery or procedure on a single detail line with CPT^® modifier 50 and a quantity of 2,” or “on 2 detail lines, one with HCPCS modifier RT and one with HCPCS modifier LT” for any claims involving procedures with a bilateral surgery indicator of 3 (i.e. for radiology procedures), the Part A/B MAC for Jurisdictions J and M notes (www.palmettogba.com/palmetto/jmb.nsf/DIDC/7RDS2E5083~Specialties~Surgery).