Pulmonology Coding Alert

Modifier -50 can bring your practice 150 percent of the fee schedule amount

You could be missing out on major reimbursement for bilateral claims if you're not clear about when to apply modifier -50 or the anatomical descriptors -LT and -RT.

Let us walk you through the do's and don'ts of the Medicare Physician Fee Schedule database to help you select the appropriate bilateral or unilateral designation with confidence.

Turn to the Fee Schedule for Guidance

Before you decide between modifier -50 (Bilateral procedure) and modifiers -LT (Left side) or -RT (Right side) for a given claim, you should consult the 2005 Physician Fee Schedule database, which is available on the CMS Web site at http://www.cms.hhs.gov/providers/pufdownload/rvudown.asp.

If you find a "1" in column "T" (labeled "BILAT SURG") of the fee schedule database, you can append modifier -50 to the code.

Example: Your physician inserts a temporary airway catheter into the right mainstem bronchus and another airway catheter into the left mainstem bronchus in a patient prior to bronchography. You should report this with 31710 (Catheterization for bronchography, with or without instillation of contrast material).

When you find this code in the fee schedule database, you'll notice a "1" in column T, and you can therefore report 31710 with modifier -50 attached to it because your physician performed a bilateral procedure.

You can expect most payers to reimburse bilateral claims at 150 percent of the assigned fee schedule amount, says Lisa Center, coding expert in Pittsburgh, Kan.

-LT and -RT May Apply if Column T Lists a '0'

A "0" in column T tells you that you cannot use modifier -50. You may report modifiers -LT or -RT, however, either in combination or singly, to make your claim more specific.

CPT added the anatomic-specific modifiers -RT and  -LT "to streamline the claims processing system, to allow for automated payment without having to request additional documentation to rule out duplicate or other inappropriate billing," according to the January 2000 CPT Assistant.

Don't Expect to Use -50 or -LT/-RT With All Codes

If there is a "1" in the fee schedule database's column T, you should append modifier -50, says Vicky O'Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo.

A "0" in column T indicates that bilateral adjustment does not apply, either because of physiology/anatomy or because the code is unilateral and there is a different code for the bilateral procedure, coding experts say.

A "2" in column T of the database indicates that the code already specifies a bilateral procedure, so you  should not append a modifier to denote a procedure's bilateral nature.

Tip: Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: Your pulmonologist performs a bronchoscopy with bronchial alveolar lavage. The documentation notes that the pulmonologist performed a saline lavage bilaterally and removed all visible secretions from the tracheobronchial tree.

If you refer to the 2005 Fee Schedule, CMS designates 31624 (Bronchoscopy [rigid or flexible]; ... with bronchial alveolar lavage) with a "0". Therefore, you should report this procedure with 31624, but you should not append modifier -50.

Seek Advice From Private Payers in Writing

When dealing with non-Medicare payers, you should ask your insurers how they want you to report modifiers -50 and -LT/-RT.

Not all private payers follow CMS guidelines. Some insurers will specify when they prefer modifier -50 and when they require modifiers -LT/-RT. Other payers prefer modifiers -LT/-RT in all circumstances because they think those modifiers are more specific than modifier -50.

Even when requiring modifier -50, some payers have different ways that they want you to report the services. 

Some carriers might prefer you to report your procedure code using two line items, appending modifier  -50 to the second code (i.e., 31710, 31710-50). Other carriers might want the code reported only once, with modifier -50 appended (i.e., 31710-50).  

Protect yourself: Always be sure to get the payers' coding recommendations and payment guidelines in writing in the event of audits or claim reviews, coding experts say.