Pulmonology Coding Alert

Question: Our pulmonologist biopsied the bronchioalveolar regions of a patient’s left and right lungs using needle aspiration. We reported 31629-50 and did not get paid the bilateral fee. Should we appeal?

New Jersey Subscriber

Answer: No, it’s not necessary to appeal the claim. In this situation, you are correct to report 31629 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)). However, you don’t need to append modifier 50 (Bilateral procedure) because this code has a bilateral indicator of “0,” suggesting that the bilateral surgery rules don’t apply. By reviewing the code descriptor, you can often determine this without consulting the fee schedule, since it refers to “biopsy(s)” and “bronchus(i),” indicating that the code applies whether one or more biopsies are taken.

Tip: Before you decide which modifier best suits a given claim, you should consult the 2020 Medicare Physician Fee Schedule database, which is available on the CMS website and offers the following bilateral indicators for each code:

• 0: Bilateral surgery rules don’t apply, and you should not use modifier 50.
• 1: Bilateral surgery rules apply and you can collect 150 percent of the fee schedule amount if you use modifier 50 or LT/RT (Left side/Right side) when the procedure is performed bilaterally.
• 2: Bilateral surgery rules do not apply because the code is already priced as bilateral, so you should not use modifier 50.
• 3: The standard payment adjustment for bilateral procedures does not apply and you can collect 100 percent of the fee schedule amount for each side. Typically services with a “3” refer to radiological or other diagnostic tests.
• 9: The bilateral surgery concept does not apply.

In most cases, pulmonology coders will see the indicators of 0, 1, and 2 on the fee schedule. You’ll find the “3” and “9” indicators much less frequently for the chest codes.

When dealing with non-Medicare payers, you should review policies or ask your insurers how they want you to report modifier 50. Not all private payers follow CMS guidelines. Some carriers might want you to report your procedure code using two line items, appending modifier 50 or LT/RT to the second code. Other carriers might want the code reported only once, with modifier 50 appended.

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.