Outpatient Facility Coding Alert

Question: Can you bill CPT^® code 42808 bilaterally?

Michigan Subscriber

Answer: In order to determine whether or not you may bill a CPT^® code bilaterally, you should determine the code’s bilateral status indicator, located within the Medicare Physician Fee Schedule (MPFS). According to CMS, the bilateral status indicators are as follows:

• 0 — Bilateral surgery rules do not apply. Do not use 50 modifier.
• 1 — Bilateral surgery rules apply (150%). Use 50 modifier if bilateral. Units = 1.
• 2 — Bilateral surgery rules do not apply. Already priced as bilateral. Do not use 50 modifier. Units = 1.
• 3 — Bilateral surgery rules do not apply. Do not use 50 modifier. Units = 1 or 2.
• 9 — Bilateral surgery concept does not apply.

The fee schedule for code 42808 (Excision or destruction of lesion of pharynx, any method) indicates a bilateral status of 0. This means that you should not bill this service bilaterally under any circumstances. This also means that you should not apply modifier 50 (Bilateral procedure) or the LT (Left Side) and RT (Right Side) modifiers.

However, if the provider excises two separate lesions on contralateral sides of the pharynx, you may still bill 42808 twice, applying modifier 59 (Distinct Procedural Service) to one of the two codes. Additionally, you may consider modifier XS (Separate Site) for Medicare Part B patients.

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