Otolaryngology Coding Alert

'1' Means -50 Is a Go

If Medicare labels a procedure's "T" column (labeled "BILAT SURG") with a "1," you have a modifier -50 (Bilateral procedure) green light. When an otolaryngologist performs an identical procedure on both sides, you may report the code using modifier -50.

Example: An otolaryngologist performs bilateral total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]). When you look at 31255's column "T" designation, as well as all other functional endoscopic sinus surgery [FESS] codes 31233-31294, you notice a "1." So you may report 31255 with modifier -50.

Depending on your payer's preference, you may report a bilateral ethmoidectomy using one or two lines. Most Medicare carriers prefer that you list the code once with the bilateral modifier appended, says Susan Smith, CPC, billing supervisor at Otolaryngology Head & Neck in Milwaukee, Wis. Private payers may prefer you list the procedure twice and append modifier -50 to the second procedure only.

Payment: Most insurance companies reimburse bilateral claims at 150 percent of the code's assigned fee schedule amount. So you can usually expect about an additional $225 for a bilateral ethmoidectomy. Example: HGSA (Medicare Pennsylvania) pays 31255 at a participating rate of $478.02 and would reimburse a bilateral ethmoidectomy at $717.03. (For more on bilateral payments, see "You're Responsible for Modifier -50 Reimbursement".)

'0' Negs -50, Permits Other Modifier

Although finding a "0" in column "T" puts a stop on modifier -50, another modifier may describe the circumstances. Some possibilities that you may consider include: 

Scenario: An otolaryngologist performs malignant tumor excision on the left and right sides of the maxilla.
 
In this case, you would use modifier -59 to indicate separate tumor excisions, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.

Reason: The maxilla (roof of the mouth) is not a bilateral structure, as the ears are. Therefore, 21034 (Excision of malignant tumor of maxilla or zygoma) has a bilateral indicator of "0."

Bilateral procedures require the otolaryngologist to perform identical procedures on the opposite side of the body (mirror image). But in 21034, the surgeon could excise different size tumors in different right and left side facial locations. While the maxillary tumors may occur on opposite sides of the face, "the otolaryngologist excises separate tumors, not bilateral tumors," Cobuzzi says. Therefore, you would use modifier -59 to indicate separate sites.

CMS Builds Bilateral Into '2'

When column "T" reveals a "2," you should throw modifier -50 out of contention. The designation indicates that the code already specifies a bilateral procedure.

Your response: You don't need to append modifier -50 to the code to denote the procedure's bilateral nature. Often, you can readily identify such codes because their CPT descriptors contain terms like "unilateral" or "bilateral."

Example: An otolaryngologist removes impacted cerumen from a patient's ears. Even though the physician removes the impaction on both sides, you should report 69210 (Removal impacted cerumen [separate procedure], one or both ears) without modifier -50. "The procedure code description specifically indicates the words 'one or both,'" states BlueCross BlueShield of Tennessee.

Watch out: Some codes imply bilateral services without using key phrases. For instance, audiometry testing (such as 92552-92557) is a bilateral procedure, even though the codes' descriptors don't state "one or both" ears. You have to use modifier -52 (Reduced services) if an audiologogist performs a test on one ear, according to CPT's instructions on audiologic function tests.

'9' Signals Nonaccepted Code

If you find a "9" in column T, the concept of bilateral surgery does not apply to that code. Medicare reserves this designation for codes that CMS doesn't recognize, such as immunotherapy codes 95120-95134 (inactive) and hearing aid codes 92590-92595 (noncovered).