Pulmonology Coding Alert

Question: If I perform a therapeutic thoracentesis (32000) on a patient, but the procedure is bilateral, what modifier would be used? Also, do I bill the code twice or bill it as two units?

South Carolina Subscriber

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Answer: If you use Medicare guidelines as your standard when reporting professional services, this procedure would be coded 32000-50.

The 32000 (thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) covers the surgical procedure only. Appending modifier -50 indicates to the carrier that a bilateral procedure was performed. According to CPT, the -50 modifier (bilateral procedure) indicates, Unless otherwise identified in the listings [of codes], bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five-digit code or by use of the separate five-digit modifier code 09950.

According to the current Medicare relative value fee schedule, modifier -50 has a 0 indicator, which means the 150 percent payment adjustment for bilateral procedures does not apply. If a procedure is reported with modifier -50 or with modifiers -RT (right side) and -LT (left side), base the payment for the two sides on the lower of the total actual charge for both sides or 100 percent of the fee schedule amount for a single code.

For example, the fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) because it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category because of physiology or anatomy or because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. Essentially, this means you can use modifier -50, but you will be paid only for a single service and not the additional 50 percent that is typical when using modifier -50.

If your carrier is not Medicare and does not recognize the -50 modifier, you should verify with the carrier its specific mechanism for reporting the service (i.e., reporting the code twice or once with a unit of two) so that the insurer does not mistake the claim as a duplicate. Consider asking about the -RT and -LT modifiers to further clarify the bilateral nature of the procedure.

You Be the Coder is answered by Mary Mulholland BSN, RN, CPC, a reimbursement analyst at the department of medicine in the hospital of the University of [...]