Wiki 50 modifiers & Texas Medicare

[Thouvenel]

I am needing some assistance when billing bilateral procedures and billing Medicare through Novitas....I am no seeing correct reimbursement when the surgeon is performing bilateral procedures, ex: total knee replacement, bilateral. It appears from the few I've seen only reimbursement is being received on one when the 50 modifier is used instead of the RT and LT. Is anyone else having this same issue? Novitas website states to bill with the 50 modifier for Texas, but I noticed another state was informed to use the RT and LT, the 50 modifier was only used for informational purposes.

 

[sriniphysio1@gmail.com]

50-modifier

Hi

NO, 50 modifier is an payer modifier only. you need to know 50 modifier from Billing purpose. eg knee replacement bilateral value is 2000$ but when append 50 modifier the insurance will pay 75% only because the surgeon do separate prep and drep for each
procedure then you need to append rt/lt and then surgeon get 100% payment. this is my point.

Thanks
Srinivasan.V CPC

 

[mitchellde]

That is incorrect, The mcare provider manual tells us to use the 50 modifier on a unilateral procedure when performed bilateral with 1 unit of service. you do not bill 2 line items just one. the reimbursement is 150% which is as it should be. There are some payers such as BC/BS that prefer the 2 line item approach using LT and RT modifiers. listing 2 line items with RT and LT will still provide a total of 150% reimbursement as the second line will discount.

 

[OCD_coder]

I have to agree with Debra. 1 line, modifier 50, 1 unit. The MUE edits were changed this year and only allow 1 unit for some CPT codes that used to be 2, especially for unilateral codes on extremities.

Although, I do suggest know your local carrier(s) rules, our local BCBS (Anthem) asks for 1 line, mod-50, 1 unit. Our local UnitedHealthcare follows Medicare rules. Aetna will accept either format, but we have our coders enter all carriers the same and we are not getting denials so far. Colorado Medicaid pays 180% of the primary CPT code, just an FYI.

 

[josephmglick]

I have to agree. One line item with 50 modifier. My local BCBS does not accept the 50 modifier for surgical procedures so its best to know what your carriers accept.