Wiki 63047 denying for modifier ....

[tmarugg]

Recently Tricare began denying 63047 stating "...INHERENT BILATERAL PROCEDURE WITH UNITS GREATER THAN ONE...."

The procedure done was "DECOMPRESSION OF L3 & L4 LAMINECTOMY WITH BILATERAL FORAMINOTOMIES"

The original claim was sent with 63047 x1 & 63048 x1 & 69990 x1.

According to the CPT description of 63047 is can be unilateral or bilateral. I have corrected the claim and appended modifier -50 to 63047.

But after doing so, I began to think, since this is a bilateral procedure and we should be getting reimbursed 150% of the allowed amount, should we be adding modifier -50 to all payers for the bilateral procedures?

 

[avon4117]

L3-L4 is a single segment so you should be billing only 63047 only along with the scope 69990. You cannot append with a modifier.

 

[mhstrauss]

I thought I'd remembered seeing similar denials here, but looking back through the last few months, i'm not seeing any for this code.

I can say this--per the CMS RVU files, 63047 has a bilateral indicator of "2":

If the indicator is "2," the 150 percent payment adjustment for bilateral procedures does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If procedure is reported with modifier –50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code.

And based on the wording in the code description "unilateral or bilateral", mod 50 should not be used.

I'm not sure what modifier they are expecting to see though. Were any other codes billed on the same DOS?

 

[tmarugg]

No other codes...

Those are the only codes that we billed. I've spoken to our Tricare representative at length and have argued until I turned blue that modifiers -50, -RT, or -LT is not required for 63047. But she insists that medical review states it is required. So I'm throwing in the towel and just submitting it the way they say so. Thanks for this input on this one ladies. I really appreciate it.