Pulmonology Coding Alert

Modifiers 101:

Bolster Your Bilateral Procedure Claims With Correct Modifier 50 Use

Published on Mon Feb 07, 2022

Tip: Make sure to get payer guidelines in writing.

Pulmonologists perform several procedures on both sides of a patient’s body to diagnose or treat conditions affecting their respiratory system. If you’re not appending the correct modifier to applicable procedure codes, you could be leaving money on the table for your practice.

So, here’s how you correctly append procedure codes with modifier 50 (Bilateral Procedure).

Pay Attention to Descriptors Before Appending Modifier 50

You can append modifier 50 to a diagnostic procedure code when the provider performs the procedure on both sides of the body during the same session. The modifier can be appended only to procedure codes performed on paired organs, such as the lungs, or paired body structures, like extremities, eyes, and ears. “Things to look for in the note would be ‘both sides,’ ‘bilateral,’ ‘left and right,’” says Sherrie Lynne Anderson, MS, CPC, CPC-I, CPPM, CRC, of the Revenue Cycle at the Washington University Department of Neurology, School of Medicine.

However, there is a catch to using the modifier. You will use modifier 50 to indicate a procedure was performed bilaterally, but if a procedure code descriptor includes the words “bilateral” or “unilateral or bilateral,” you can’t append modifier 50 to these codes.

Example: A provider performs a bilateral endoscopy on a patient’s nose to examine the nasal cavity structures. You’ll assign 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)) to report the procedure, but you can’t append this code with modifier 50. The code descriptor calls out “unilateral or bilateral,” which makes modifier 50 unnecessary.

Important: Appendix A of the CPT^®code set lists the modifiers applicable to CPT^®2022 codes. Modifier 50 features a note instructing that you shouldn’t append the modifier to add-on codes.

Check MPFS to Help Avoid Denials

If you’re unsure whether the code you’re reporting allows modifier 50 for accurate reimbursement, you should consult the 2022 Medicare Physician Fee Schedule (MPFS) database on the Centers for Medicare & Medicaid Services (CMS) website

(www.cms.gov/medicare/physician-fee-schedule/search). Each code features one of the following bilateral indicators:

0: Bilateral surgery rules don’t apply, and you should not append modifier 50.
1: Bilateral surgery rules apply, and you may collect 150 percent of the fee schedule amount if you append modifier 50 or LT (Left side)/RT (Right side) when the procedure is performed bilaterally.
2: Bilateral surgery rules don’t apply, since the RVU is already priced as bilateral.
3: The standard payment adjustment for bilateral procedures doesn’t apply. You can collect 100 percent of the fee schedule for each side. Note: Services with a “3” indicator usually refer to radiological or other diagnostic tests.
9: The bilateral surgery concept doesn’t apply.

(Source: www.cms.gov/files/document/2020-physician-fee-schedule-guide.pdf)

After you input the code into the search engine, you’ll receive a table with the search results. When you scroll to the right, you’ll find a column labeled “Bilt Surg,” which is where you’ll find the bilateral indicator. When you search for 31231 (as in the example listed above), the code receives a bilateral indicator of “2,” confirming that modifier 50 is not necessary because Medicare prices 31231 as a bilateral service.

Note: You’ll see indicators of 0, 1, and 2 on the fee schedule for most pulmonology coding cases.

Build Your Bronchoscopy Modifier Coding Skills

Scenario: A patient is referred to your pulmonology practice for a bronchoscopy after X-rays revealed an abnormality near the patient’s airway. Your pulmonologist used needle aspiration to biopsy the bronchioalveolar regions of a patient’s left and right lungs.

In this situation, you’ll assign 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)) to report the bronchoscopy with transbronchial needle aspiration (TBNA) biopsy. But do you need to also append modifier 50 to the code?

In this case, modifier 50 does not apply to code 31629. If you consult the MPFS, you’ll see a bilateral indicator of “0,” which tells you the bilateral surgery rules don’t apply.

Additionally, the code features a parenthetical note under the descriptor in the code set that instructs you to report the code only once “for upper airway biopsies regardless of how many transbronchial needle aspiration biopsies are performed in the upper airway or in a lobe.”

Relieve the Confusion of Bilateral Thoracentesis Coding

Scenario: A patient presents to your pulmonology practice with difficulty breathing, shortness of breath, and pain while breathing. The physician diagnoses the patient with pleural effusion and performs thoracentesis on the patient’s left and right sides.

For this scenario, you’ll assign 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance) to report the thoracentesis. Additionally, you’ll append the code with modifier 50 to indicate the bilateral procedure. There isn’t an indicator of laterality in the code descriptor, so you’ll need to use the modifier to ensure proper reimbursement.

When you consult the MPFS, 32554 has a bilateral code indicator of “1,” which means the bilateral surgery rules apply and you can collect up to 150 percent of the fee schedule amount when you append modifier 50 or LT/RT.

Get Payer Preferences in Writing

To ensure the success of your claim, you should check individual payer guidelines for the correct use of modifiers when coding bilateral procedures. Medicare provides clear instructions on the CMS website, but not all private payers follow CMS guidelines, so you should review the policies of your payers and ask them how they want you to use modifier 50. Also, some private insurers might want you to use two line items to report the procedure code, appending modifier 50 or LT/RT to the second code. Other payers may only want a code reported once with modifier 50 appended.

Regardless of the payers’ coding instructions, always get their coding recommendations and payment guidelines in writing. Coding experts say having that information written down is important in the event of an audit or claims review.