Optometry Coding & Billing Alert

Question: I need some information on billing bilateral procedures. For Medicare, should I report the code only once with modifier 50 using a quantity of one or two on the first line? If so, would I double the fee?

Oregon Subscriber

Answer: Medicare generally wants you to use only one line with modifier 50 (Bilateral procedure) and a quantity of one.

Example: Using forceps, an optometrist removes one lash from a patients left lower eyelid and two lashes from the same patients right upper eyelid. On the Medicare Physician Fee Schedule (MPFS), 67820 (Correction of trichiasis; epilation, by forceps only) has a bilateral procedure indicator of 1, meaning the code is eligible for bilateral reporting using modifier 50.

Medicare bases the payment for these codes when reported as bilateral procedures on the lower of:

(a) the total actual charge for both sides, or

(b) 150 percent of the MPFS amount for a single code.

This means that you will want to adjust and report your charge as at least 150 percent of the usual charge for a unilateral procedure in order to receive accurate payment from your carrier.