Orthopedic Coding Alert

Modifiers:

Gain Universal Knowledge of Bilateral Modifier With This Quick Q&A

Published on Mon Apr 06, 2020

If code indicates bilaterality, leave modifier 50 off the claim.

If the provider performs a procedure on both sides of a patient, you should report the appropriate CPT^® code, slap modifier 50 (Bilateral procedure) on the claim, and file it … right?

Answer: Yes … sometimes. But a bilateral procedure doesn’t necessarily guarantee a modifier 50 gets included on a claim. There are some instances where the modifier isn’t necessary, and others where different modifiers might be more appropriate.

To help you sort through the do’s and don’ts of modifier 50 coding, we spoke to Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America; and

Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. Here’s what they had to say about modifier 50.

Q: When is modifier 50 necessary?

A: Hauptman The 50 modifier is necessary when the procedure being performed is being done on both sides of the body, but doesn’t already have the verbiage in the description of the code.

Bucknam A coder should apply modifier 50 whenever the same procedure (same exact CPT^® code) is performed on bilateral structures of the body during the same operative session and the code that describes the service is not defined as bilateral — note some procedures have separate codes for unilateral or bilateral, depending on which is done, and it would be inappropriate to use modifier 50 on the unilateral code instead of choosing the bilateral code.

For those who are more familiar with the Medicare indicators, use modifier 50 with CPT^® codes that have indicators 1 or 3. Codes with indicators 0, 2, and 9 should never be billed with modifier 50. There are also some circumstances where modifier 50 might seem appropriate but it is not. For example, if the same size lesion is removed from each, arm modifier 50 should not be used. Modifier 59 [Distinct procedural service] is appropriate because the service was performed on a different area of the body. The skin is considered to be a single — very large — organ.

Q: So, when the provider performs certain procedures bilaterally, you should append modifier 50 to the procedure code and report the code once?

Hauptman Yes, again if the descriptor does not include bilaterality already, then, the 50 modifier is appropriate. Keep in mind that with ICD-10, if the diagnosis says both sides, but the CPT^® code does not, the 50 modifier is still needed.

You will also want to check with the payer, as they may want to see modifiers RT [Right side] and LT [Left side] on two separate lines instead of the 50 modifier. We had that come up with United HC around breast reconstruction surgeries.

Bucknam Also, it would be smart to consider whether other modifiers might be more informative. For example, removal of ingrown toenail might be performed on both great toes, but it would probably be better to use the modifiers specific to each toe than add modifier 50 since there are so many toes.

Also, not every payer wants modifier 50 reported the same way. Medicare typically wants the service reported on one line with modifier 50 and 1 unit; but other payers have other rules, and you can lose a lot of money if you don’t follow those rules.

Q: So, can you explain more about the use of modifiers LT and RT?

Hauptman LT and RT are most often used when you are performing a procedure on one side of the body which, at some point, might be performed on the other side. Perhaps you provide a closed treatment of greater humeral tuberosity fracture without manipulation (23620 [Closed treatment of greater humeral tuberosity fracture; without manipulation]) on the left arm. You would want to indicate LT in the event that this person might have this performed on the right side as some point; or just for further clarification. Again, note that with your ICD-10 coding, you would be required to indicate the side, or at least unilateral versus bilateral. But that is not a substitute for proper CPT^® nomenclature.

Bucknam There are some circumstances when LT and RT are better or more descriptive than 50. Medicare generally allows either LT/RT on two lines or 50, and pays them the same. But not all payers do so. Radiology services are often paid better when LT and RT are used.

Also, I like to use LT and RT when slightly different procedures were performed on opposite sides of the body, especially if one is more extensive than the other, because it is very informational. However, if you are going to use LT/RT be sure that you use the right one. I’ve seen quite a few claims where LT was used when the right side of the body was treated, or vice versa, and it can be very confusing if there is subsequent treatment that contradicts what was on a previous claim.

However, I will add that we are seeing denials when an unspecified location ICD-10 code is used with a CPT^® code that has an LT or RT on it. The ICD-10 code needs to match the modifier on the CPT^® code.

Additionally, something new that was emphasized at the AMA [American Medical Association] code changes symposium this year is how to code when you have a bilateral procedure that also has an add on code that was performed bilaterally. The main code should be billed with modifier 50, but modifier 50 should not be used on the add on code. It should be billed with 2 units.