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Otolaryngology Coding Alert

You're Responsible for Modifier -50 Reimbursement

Published on Wed Apr 06, 2005

Not doubling 31267 fee could cost you $175 plus

You can avoid shorting yourself maxillary antrostomy bilateral procedure dollars provided you bill based on the insurer's preferred method.

The modifier -50 (Bilateral procedure) payment method depends on the line entry. Coders have to realize when to double the fee and when not to, says Susan Smith, CPC, billing supervisor at Otolaryngology Head & Neck in Milwaukee, Wis. Otherwise, they'll risk the additional 50 percent payment for the bilateral side.

Here's how you can assure correct payment:

Use Same Charges With Double Entry

Method 1: Many private payers, such as Regence BlueShield of Washington, instruct you to report bilateral procedures using separate lines. When you use multiple line entries, the insurer will pay you for both procedures.

Example: Jim had an endoscopic maxillary antrostomy in which the otolaryngologist removed sinus contents, right and left. You should report the procedure code on two lines with modifier -50 on the second procedure or line, instructs Regence BlueShield.

The claim would be coded as follows:
 

  • 31267                   No MOD            1 unit               Normal fee for 1
                                                                                   (such as $352.07)
     
  • 31267                   50 MOD             1 unit              Normal fee for 1       
                                                                                   (such as $352.07).

    Recalculate Single Line Fee

    Method 2: Some insurers, such as Medicare, Blue Cross Blue Shield (BCBS), and Oxford, require a one-line claim. You should file bilateral procedure as "a single line item using the appropriate procedure code with Modifier 50 and one unit," states BCBS of Tennessee.

    Example: For BCBS, you would report:
     

  • 31267                          50 MOD                     1 unit  Double your fee, manually
                       (for instance $704.14; Medicare allows $528.10.)

    Watch out: If you use a single line entry, you will have to double your fee. The carrier will not do this for you, Smith warns.

    Units count: Notice that you should enter a modifier -50 charge using one unit, not two. Modifier -50 indicates the dual nature of the procedure, states the University of Michigan Health Systems. "Providers who bill Modifier -50 with a count of two will see the following denial code: MW - Provider billing incorrectly with modifier -50 and a count of two."

    Reduce Additional Bilateral Charges by 50 Percent

    The same 150 percent bilateral procedure code payment rules should also apply to multiple bilateral procedures provided the insurer follows Medicare bilateral surgery payment rules.

    Catch: When a claim contains multiple bilateral procedures, it's also subject to Medicare's multiple procedure payment rules. "We have one carrier that states that on the secondary bilateral procedure, it should be priced at 150 percent of their fee schedule and then divide this in half," says Leslie Pirkl, coding specialist at Mercy Iowa City. So the insurer allows 150 percent of the primary procedures and 50 percent of the secondary procedures.

    WPS (Wisconsin Medicare) confirms the payment reduction method. If you report a second surgery bilaterally, and multiple surgery rules apply, the carrier will reimburse it at 50 percent of the 150 percent fee schedule amount, the insurer states.

    Example: Suzie undergoes a bilateral anterior ethmoidectomy and bilateral maxillary antrostomy.

    For Medicare, you would report:
     

  • 31254    50 MOD              1 Unit               Double fee for 1   
     (Charge $601.80; Medicare allows $451.36)
     
  • 31256    50 MOD              1 Unit               Double fee for 1
     (Charge $453.06; Medicare allows $163.15).

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