Radiology Coding Alert

Medicare fee schedule meddles with bilateral compensation

You may think there's not much difference between "0" and "1," but that difference could cost you big bucks.

CMS changed the bilateral status indicator for a number of codes, including selective catheter placement of the arterial system (36215-36216), from "1" to "0," in Transmittal 661 (Change Request 4031), dated Aug. 26.

A "1" means that if you report a given procedure with modifier 50 (Bilateral procedure), or as separate items with modifiers LT (Left side) and RT (right side), Medicare will pay you 150 percent of the allowable fee. Technically the total payment is for a single side. If the status is "0," however, the payer will cover only the allowable for a single side even if you bill the code with modifier 50 or with LT and RT. (See Medicare Claims Processing Manual, Chapter 12, p. 84 for rules on 50, RT, and LT.)

Example: An interventional radiologist catheterizes the right common carotid and the left vertebral, both of which are second-order vessels. Old way: You used to be able to code this scenario with 36216-LT (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family) and 36216-RT, earning 150 percent of the allowable fee for 36216, says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga. New way: With the recent change to the "0" indicator, this same scenario will earn you payment for only one unit, she says.

If you need to report a code multiple times, but you can't use bilateral modifiers, experts say that you may be able to use modifier 59 (Distinct procedural service). Many multiple catheterizations aren't actually bilateral, so 59 is more appropriate than 50. But remember, your claims will be subject to the multiple-surgery discount (50 percent), just like before.

HOCM fee hike: The fee schedule update also includes Q9958-Q9964, the new codes for high osmolar contrast material (HOCM), but only as non-covered codes.

CMS said in the 2006 Physician Fee Schedule proposed rule that Medicare will pay for Q9958-Q9964 starting in January. CMS will add RVUs to the HOCM codes by taking some RVUs away from exams that use contrast, so you may not see any additional reimbursement. But you could lose reimbursement if you forget to add the HOCM codes next year. You can find out more about the October update to the 2005 fee schedule at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM4031.pdf and www.cms.hhs.gov/manuals/pm_trans/R661CP.pdf.

Watch for: The proposed 2006 fee schedule brings more reimbursement hits. You could see a multiple- procedure reduction--a 50 percent reduction in reimbursement for the technical component of second and subsequent diagnostic imaging services of contiguous body parts. Good news: Professional societies are working to convince CMS this cut is far too hash. See www.cms.hhs.gov/physicians/pfs/ama.asp?URL=/providerupdate/regs/cms1502P.pdf (starting on page 88) for more information.