Radiology Coding Alert

Here's how to choose between modifiers -50, -LT and -RT

To determine when to apply modifiers -50 (Bilateral procedure), -LT (Left side) and -RT (Right side), you should use the following expert advice and the Physician Fee Schedule database to select the appropriate modifier with confidence every time.

First step: Before you decide between modifier -50, -LT and -RT for a given claim, you should consult the 2005 Physician Fee Schedule database, which is available on the Centers for Medicare & Medicaid Services Web site at www.cms.hhs.gov/providers/pufdownload/rvudown.asp.

Step 1: Know When -50 Applies

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: An angiogram occurs when the radiologist inserts a catheter into the blood vessel, injects x-ray dye (contrast), and takes x-rays. The procedure for both renal arteries is coded 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family). If you don't add the left and right modifier to signal that both were involved, one could be denied as a duplicate.

Some payers prefer modifier -50 for a truly bilateral structure like the renal arteries. In this case, append -50 to the surgical code the second time you report it (36245, 36245-50). When you find 36245 in the Physician Fee Schedule database, you'll notice a "1" in the "BILAT SURG" column, and you can therefore report 36245-50.

Depending on payer preference, you should either list the code once with the bilateral modifier appended (this is the method most Medicare carriers prefer) or list the procedure twice and append modifier -50 to the second procedure only, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Because most payers reimburse bilateral claims at 150 percent of the assigned fee schedule amount, you can usually expect about an additional $135 for this procedure (for a total payment of $410, based on national average payment using 2004 fee schedule figures).

The code descriptors often give you a hint regarding whether the procedure will garner more reimbursement if you append modifier -50, says Suzan Hvizdash, BSJ, CPC, physician education specialist at the University of Pittsburgh's department of surgery. If the descriptor indicates a bilateral procedure, modifier -50 won't bring you more money.

If you find a "0" in column "T,"  it means that modifier -50 is not allowed. You may report modifiers -LT or -RT, however, either in combination or singly, to make your claim more specific.

Step 2: X-Rays May Need -RT/-LT

When billing x-rays, the question often arises whether an office should bill bilateral x-rays using modifiers -RT,  -LT or -50.

For Medicare claims, appending modifier -50 is a no-no because the modifier was intended for surgical procedures, not radiology, says Carla Mulcay, CPC, CPC-H CMC, RCC, assistant director of coding at Medquest Associates in Alpharetta, Ga. And many of the radiology procedure codes specify unilateral, bilateral or both in the code definition.

For example, in its radiology manual, CIGNA Healthcare states, "The most appropriate away to submit bilateral x-rays is to bill the procedure code on separate lines with the appropriate -RT and -LT modifiers (do not use the bilateral modifier -50)."

Therefore, to specify which foot on a Medicare claim for an x-ray, you can only append modifiers -LT and -RT. If it's a toe x-ray, one of the toe modifiers, like -T3 (Left foot, fourth digit), is the way to go. Some private carriers may require modifier -50, Mulcay says, so you should check with the insurance carriers to find out what they prefer.

Don't be fooled: Always check the fee schedule - just because something appears to be bilateral doesn't always mean it is. In other words, never simply assume you're right.

Step 3: Skip -50 When CPT Defines 'Bilateral'

If you find a "2" in column "T,"  it indicates that the code already specifies a bilateral procedure, so you should not append a modifier to denote a procedure's bilateral nature. Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: The radiologist x-rays a patient's ribs. You report 71110 (Radiologic examination, ribs, bilateral; three views). You do not need to attach modifier -50, because 71110 specifies a bilateral procedure.

Step 4: No. 9 Means No Modifiers

If you find a "9" in column "T,"  the concept of bilateral procedures does not apply to that code. Therefore, you should never claim modifier -50 or modifiers -LT/-RT in combination for that procedure.

Example: The physician uses an ultrasound for volume and mapping of prostate brachytherapy treatment, so you report 76873 (Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]). Because this code has bilateral status of "9," you should not append -50, -RT or -LT to it.

Seek Advice From Private Payers in Writing

When dealing with private 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.

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