Part B Insider (Multispecialty) Coding Alert

Some payors phase out 50 modifier as "pricing modifier"

In a perfect world, you'd be able to bill every payor the same way, with the same rules. Unfortunately, private payors often choose their own route, which makes your life more complicated.

When you bill Medicare for a bilateral procedure using the 50 modifier, the rules are pretty simple: You bill the code once, with the 50 modifier attached. Then the Medicare carriers automatically increase your reimbursement to 150 percent of the code's usual RVUs.

But many private payors and state Medicaid programs have wildly different rules. Some of them want you to bill the code twice, on two lines, with the 50 modifier attached to the second line. Others require you to bill two units of the code on one line, and attach the 50 modifier.

Blue Cross/Blue Shield of South Carolina recently wrote to providers to say that it would no longer recognize the 50 modifier with a single unit on a single line, according to Hidy Borden, senior reimbursement analyst with the Medical University of South Carolina in Charleston. Instead, providers must either use two lines, or two units on a single line.

To add to the confusion, the change applied to some of the Blue Cross health plans, but not others. And the Blues rep claimed the change also applied to South Carolina Medicare, which Blue Cross oversees as Palmetto GBA. But so far no sign of the change has appeared on Palmetto's Web site, and this would be a dramatic departure from other Part B Medicare carriers' practices.

The reason for the change? The Blue Cross plan no longer recognizes the 50 modifier as a "pricing modifier." In other words, the 50 modifier would no longer automatically trigger a change in reimbursement by itself, unless there were multiple units.

Use Computers To Tailor Bilateral Claims

Borden says MUSC uses an "up-front editing process" in its computer systems to scrub the claims. That way, carriers that want multiple units will receive them, while others will continue to have single units.

Caution: If you bill a code on two lines using the 50 modifier, you could wind up overcharging if a payor actually requires you to bill only once, warns Laureen Jandroep with the CRN Institute in Absecon, NJ. In that instance, the payor will pay you 150 percent for the code with the 50 modifier, plus another 100 percent for the second instance of the code.

Monitor your Explanation of Benefits (EOB) forms to make sure you're not accidentally receiving 250 percent or 100 percent instead of the 150 percent you should receive, Jandroep advises. She tells of one ear, nose and throat practice that was routinely billing on two lines using the 50 modifier and receiving 250 percent, and posting that payment without checking. The practice ended up with a huge overpayment.

"I recommend to my clients that they check with their top three or top five payors" to find how how they prefer the 50 modifier, says Jandroep. If your top payors want the 50 modifier billed as a single line, then you should follow that rule and keep an eye on your EOBs, she suggests.

Some payors don't use the 50 modifier at all, says Alameda, CA podiatrist Anthony Poggio. In that case, you may have to use two lines, with the LT and RT modifiers, even with codes for which Medicare prefers the 50 modifier.

Remember: It's important to make sure you're doing exactly the same procedure on each side, Poggio cautions, or the 50 modifier doesn't apply anyway.

Note: It's okay to use the 50 modifier more than once on the same date of service, says Part B Carrier Arkansas Blue Cross Blue Shield. The Arkansas Blues had warned providers not to bill for bilateral procedures more than once per day back in 2002, but has since revised that guidance, per the Centers for Medicare & Medicaid Services.

Nevertheless, the multiple procedure rules do apply - meaning the first bilateral procedure will pay 150 percent and the second bilateral procedure will pay 75 percent.