Urology Coding Alert

Tip: Determine the best modifier using Medicare's Physician Fee Schedule

When your urologist performs a bilateral procedure such as a cystourethroscopy and bilateral double-J stent insertion, you're missing out on reimbursement if you don't append the correct modifier. Use the following expert tips to ensure you're using modifiers LT, RT, and 50 correctly to show payers that your physician deserves additional compensation for the bilateral surgery.

Refer to the Fee Schedule for Guidance

Before deciding between modifiers 50 (Bilateral procedure) and LT (Left side) or RT (Right side) for a given claim, you should consult the 2006 Physician Fee Schedule database to see if appending a bilateral modifier is even allowable.
 
Look at column "T" of the spreadsheet, labeled "BILAT SURG." If you see a "1," you can use modifier 50 for that particular code and expect to receive 150 percent payment, says Barbara E. Oviatt, CPC, CCS-P, coding supervisor at Martin Memorial Medical Group in Stuart, Fla.
 
Here's how: Submit your claim with the code listed twice, once with modifier 50 and once without, and put modifier RT on one and modifier LT on the other. The payer should then process your claim and pay the urologist a total of 150 percent of the standard payment.
 
But be sure to do this only with those few payers that  process claims this way, because those that follow Medicare processing may pay you 150 percent on the one charge and 100 percent on the other, and when this error is discovered, the carrier will certainly ask for a refund.
 
"Medicare carriers for Part B services have published articles specifying their preference to report a bilateral service with a single line item with modifier 50 and 1 unit of service, whereas [some] non-Medicare payers prefer reporting bilateral services with two line items -- one with RT and 1 unit of service, and the second with LT and 1 unit of service," says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting, a reimbursement consulting firm in Denver. Check with your payer to be sure, because some also require the 50 on the same code on a second line with 1 unit.
 
Example: Your urologist performs a cystourethro-scopy and places ureteral double-J stents bilaterally (52332, Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]).
 
When you find this code in the Physician Fee Schedule database, you notice a "1" in column T, and therefore you should report this procedure as 52332-50 for Medicare because the urologist performed it bilaterally.

Avoid Bilateral Modifiers With '0' Indicator

If you see a "0" in column T, you should not append modifier 50. "The "0" indicator means that the payment adjustment for a bilateral indicator does not apply," Hammer says.
 
Tip: You can always use modifiers RT and LT for purely informational purposes when the physician does not perform services bilaterally, Hammer says
 
Beware: Some payers, particularly Medicare, will reject claims if LT or RT is used and there is not allowance for a bilateral procedure. Part of the logic in allowing LT and RT is for use on procedures that can be done bilaterally but are performed in another global period, experts say.
 
Example: A urologist performs a cystourethroscopy and removes bilateral double-J ureteral stents. You should not use modifier 50 with 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder; simple), according to the Medicare Physician Fee Schedule database, which shows a "0" bilateral indicator for 52310. For the cystoscopic removal of bilateral ureteral double-J stents, use 52315 (... complicated).  

Identify Inherently Bilateral Codes

If you don't find a "1" or a "0" in column T of the fee schedule database, you should avoid appending 50, LT and RT.
 
A "2" in column T of the database indicates that payers will not apply the 150 percent rule to that particular procedure code, Oviatt says. The relative value units (RVU) for such codes are already based on the fact that the procedure code represents one of the following:
 
• The code descriptor specifically states that the procedure is bilateral.
 
• The code descriptor states that the procedure may be performed either unilaterally or bilaterally.
 
• Physicians usually perform the procedure bilaterally.
 
Example: Some procedures, such as vasectomies (55250, Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]), qualify as "inherently" unilateral or bilateral surgeries, so you should not append modifier 50 or LT/RT in combination to report procedures on both the left and right side.
 
For example, the urologist performs a vasectomy, which involves cutting the vas deferens and suturing the ends, on both the left and right sides. Because the code descriptor specifies unilateral or bilateral, you should report the procedure the same way whether it's done on one or both sides. You should report this as 55250 with no modifiers appended.
 
Note: If column T includes a "9," the concept of bilateral surgery does not apply to that code. Therefore, you should never use modifier 50 or modifiers LT/RT in combination for that procedure.
 
Such procedures are relatively uncommon in a urology practice. "There is an additional indicator '3' that means the usual payment adjustment for bilateral procedures does not apply because these codes are typically radiology procedures or diagnostic tests, which are not subject to the special payment rules for other bilateral surgeries," Hammer says.
 
Protect yourself: Private-payer rules can vary greatly from Medicare guidelines when it comes to how you should use the bilateral modifiers. Always be sure to get the payers' coding recommendations and payment guidelines in writing to protect yourself in the event of audits or claim reviews.
 
Bonus: You may download the current Physician Fee Schedule database free from the CMS Web site at www.cms.hhs.gov/PhysicianFeeSched.