Otolaryngology Coding Alert

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

The CPT^® code set includes a plethora of codes that describe procedures involving anatomic structures. Although every otolaryngology coder frequently uses modifiers on their claims, sometimes the rules surrounding when to show a payer 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.

If you’ve ever found yourself stumped deciding which laterality modifier to apply, you’re not alone. And the confusion is compounded by the fact that payer guidance regarding these modifiers is all over the map. Start off on the right foot by following five simple steps that will help you land on the right laterality modifier every time.

Step 1: Evaluate Whether a Modifier Is Even Needed

There are some instances where the code has laterality built in. So, before you apply any kind of laterality 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. For example, adding a laterality modifier to 30801 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method … superficial) would not only be unnecessary, it would also be incorrect, as the descriptor specifies the code applies to an ablation on one or both sides of the nasal cavity.

Step 2: Verify Proper Application of Modifier 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., ears or extremities) will need modifier 50 if it is performed on both sides of the body. So, you would apply modifier 50 to 69210 (Removal impacted cerumen requiring instrumentation, unilateral) if an ENT uses an instrument, such as a curette or forceps, to remove entrapped wax from both the left and right external auditory canal.

In this case, CPT^® instructs you to use modifier 50 for bilateral impacted cerumen removal. However, some payers may want you to report bilateral impacted cerumen removal on two lines with modifier 50 on the second line. Others may prefer two lines with the RT modifier on one line and the LT modifier on the other. So, you will have to check payer guidelines and know each payer’s rules before submitting your claim for this service.

Beware, Medicare Part B will not pay for the removal of impacted cerumen bilaterally, so if it is submitted with a 50 modifier, it will not be paid. Practices just have to know this quirk about Medicare Part B and submit 69210 without a modifier, even if it is performed bilaterally, experts say.

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,” the Part A/B Medicare Administrative Contractor (MAC) for Jurisdictions L and H says in its online guidance (www.novitas-solutions.com/ webcenter/portal/MedicareJL/ pagebyid?contentId=00144531). This rule applies to all Medicare Part B payers.

Step 3: Assess if It’s Appropriate To Append 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).

Payer alert 2: Emblem Health follows this LT/RT policy: “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).

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 69210 example, you would not report bilateral impacted cerumen removal with 69210-50-LT, 69210-50-RT. But you would be correct in using either RT or LT if the otolaryngologist removed cerumen from only one ear.

Step 4: Double-Check the Payer’s Bilateral Guidelines

Even though CPT^® and Medicare both 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 modifier 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 services with a bilateral surgery indicator of 3 (i.e. for radiological procedures,” the Part A/B MAC for Jurisdictions J and M notes (www.palmettogba.com/ palmetto/ jmb.nsf/DIDC/7RDS2E5083~Specialties~Surgery).

Step 5: Don’t Forget the Medicare Fee Database

Before submitting the claim, check the Medicare fee database, as it might not include modifier 50 with the CPT^® code, which means that modifier 50 cannot be used. For example, if your provider destroyed intranasal lesions in both nostrils, you might be inclined to code 30117 (Excision or destruction (eg, laser), intranasal lesion; internal approach) with modifier 50. But the 50 modifier is not included in the fee database for 30117; therefore, it cannot be used with this CPT^® code. The coding for the destruction of the two lesions will depend on the payer, some requiring a 2 in the units field, some expecting LT on one line and RT on the second line, others expecting two lines, one line with no modifier and the second line with an XS (Separate structure …), whereas some payers may want modifier 59 (Distinct procedural service) on the second line with 30117.