Otolaryngology Coding Alert

Correct modifiers increase payment for bilateral sinus endoscopies

You're not alone if you have difficulty distinguishing among modifiers -LT, -RT and -50. Fortunately, with the aid of the Medicare Physician Fee Schedule database and our experts'advice, you can select an appropriate modifier with confidence.

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 2004 Physician Fee Schedule database, which is available on the CMS Web site at http://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.

Example: The otolaryngologist performs a bilateral diagnostic sinus endoscopy (31233, Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]).

When you find 31233 in the Physician Fee Schedule database, you'll notice a "1" in the "BILAT SURG" column, and you can therefore report 31233-50. Because most payers reimburse bilateral claims at 150 percent of the assigned fee schedule amount, you can expect about an additional $135 for this procedure (for a total payment of $410, based on national average payment using 2004 fee schedule figures).

Depending on payer preference, you should either list the procedure twice and append modifier -50 to the second procedure or only list the code once with the bilateral modifier appended, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

The code descriptors can often give you a hint regarding whether the procedure will reimburse you more 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.

-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.

Example: The nasal foreign-body removal code 30300 contains a "0" in column T, meaning you should not append modifier -50 to these procedures. But if the otolaryngologist removes a foreign body from the left nostril and another from the right nostril, you can report 30300-RT (Removal foreign body, intranasal; office type procedure) and 30300-LT.

If you simply report 30300 x 2, payers might reject the second unit as a redundant (repeat) procedure. By specifying -RT and -LT, you clearly demonstrate foreign-body removal from two different sites.

Note: To further demonstrate the separate nature of the injection sites, you should also append modifier -59 (Distinct procedural service) as the first modifier and -LT or -RT as the second modifier.

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.

If you don't find a "1" or a "0" in the fee schedule database's column T, you should append neither modifier -50 nor modifiers -LT/-RT. A"2" in column T of the database indicates that the code already specifies a bilateral procedure, so you should not append a modifier to denote a bilateral procedure. Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: CPT code 30801 specifies, "Cautery and/or ablation, mucosa of turbinates, unilateral or bilateral, any method (separate procedure); superficial." Because the descriptor states that the procedure is either unilateral or bilateral, you know that payers will consider modifier -50 irrelevant.

Further, the Physician Fee Schedule database assigns this code a "2" in column T. So, if the otolaryngologist performs a bilateral turbinate cautery, you should report a single unit of 30801 with no modifiers, Corcoran says.

When dealing with non-Medicare payers, you should ask your insurers how they advise 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.

Protect yourself: Always be sure to get the payers' coding recommendations and payment guidelines in writing to protect yourself in the event of audits or insurance reviews.