Primary Care Coding Alert

These 3 tips will keep payers on your side.

Modifier 50 (Bilateral procedure) is one of those modifiers that always seems to create problems for coders. That’s because it is not the only modifier you can use to indicate when your provider has performed a procedure on both sides of a patient’s body.

For example, suppose your physician removes impacted cerumen from both of a patient’s ears, and you decide to report 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral). Do you use modifier 50? Do you use Level II HCPCS modifiers RT (Right side) and LT (Left side) instead of or in addition to modifier 50? Do you use one line or two on your claim?

Here are some tips for you to use to find out if your answer will put you on the right — and the left — side of this scenario.

Tip 1: Read the CPT^® Descriptor Closely

It may seem obvious, but the first thing you should do is “look at the CPT^® descriptor for the code to which you are thinking of appending modifier 50,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “If the descriptor includes the word ‘bilateral,’ you should probably not append modifier 50,” Moore cautions.

For example, “you can apply modifier 50 to 19303 (Mastectomy, simple, complete) if a patient had a double mastectomy,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. That’s because the service is not designated as bilateral, though it can be performed on an anatomic structure or organ that is symmetrical (like the nose or the cheeks) or that is paired (like the arms, legs, ears and, in the case of this mastectomy example, breasts).

Tip 2: Do Not Add Modifier 50 to Add-Ons or When Noted

“Another common mistake made by coders, which the note for modifier 50 in CPT^® Appendix A warns against, is appending modifier 50 to an add-on code. It should only be appended to base codes not otherwise labeled as bilateral and that are done bilaterally,” Moore advises.

Additionally, you should “check to see if there is any parenthetical instruction to use modifier 50 for bilateral procedures following the code in CPT^®. If there is, that’s confirmation you can use modifier 50 with the code when the procedure is done bilaterally at the same session,” Moore adds.

Such is the case with 69209 and 69210, both of which are subject to the instruction to use modifier 50 for the procedure when performed bilaterally.

Tip 3: Do Not Add RT or LT

“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,” advises Johnson.

This corresponds with the Centers for Medicare & Medicaid Services (CMS) admonition, “Do not use modifiers RT [right side] and LT [left side] when modifier -50 applies.” The Medicare Claims Processing Manual goes on to note that “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” (Source:  www.cms.gov/files/document/chapter-4-part-b-hospital-including-inpatient-hospital-part-b-and-opps-0).

So, How Is the Scenario Resolved?

Back to our scenario where your physician removes impacted cerumen from both of a patient’s ears. In this case, you can use modifier 50 appended to either 69209 or 69210 (depending the method of removal) because 69209 and 69210 are designated as unilateral procedures and are not add-on codes. Further, parenthetical instructions to both codes note that you should use modifier 50 when the procedures are performed bilaterally, and the physician performed the procedure on both sides of a paired anatomic structure.

How to bill: It is important to note that even though CPT^® and Medicare both instruct you to use 69209 and 69210 with modifier 50 on one line of your claim in this scenario, some private payers do not follow these guidelines. Consequently, you should check with your payers, as some may want you to report bilateral cerumen removal on two lines with modifier 50 on the second line. Others may also prefer two lines with the RT modifier on one line and the LT modifier on the other.