Wiki Bilateral injection done but only authorized for one side.

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betsycpcp

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I work for a payer (workers' comp) and I'm curious to know if anyone has encountered this situation. An industrial commission hearing determined that a transforaminal injection at L4 was authorized, but the provider requested bilateral, and the reviewing physician said there was no justification for doing both sides as only one side had symptoms. So they approved a LEFT side injection only. When we got the bill it was for 64483-50. Their op report does show a bilateral injection. There's no explanation given for why they did both sides in spite of the hearing order. I can see why it was coded as 64483-50--it's accurately coded. However, we can't pay both sides so we denied it.
I'm wondering if providers usually bill it as unilateral when that's all that was authorized, even if they decided to do bilateral. Or, do payers usually recode it as unilateral and only pay one side? I don't feel comfortable changing their code since it's correct, but we can't pay it as is.

Thanks for any input.
 
Since it is coded correctly, I don't think the code or modifier should be changed. I would think the payer should pay out at the unilateral rate, regardless of the coding, since the medical necessity for the RT procedure was not established.
 
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