Wiki Can we talk "bilateral billing?"

[ollielooya]

List, I have one particular insurance company that is denying modifier 50 with 64612 code, saying that it is an invalid modifier for this type of procedure and the explanation is that since there is only one head, bilateral would not apply! Doctor performs auriculotemporal, supraorbital, occipital injections on both sides of the head for his specialized neurology practice. I am unable to obtain Anthem Federal guidelines, customer service offers varied, inconsistent answers, and unable to get a response from Escalated services at this time. I resubmitted the claim with guidelines from MCR and our local carrier. It still denied., but this is a whole different "animal". More claims are stalled pending to go out until we get an answer. I suppose we could bill one line without the modifier and receive reduced payment, but this just seems so wrong. So far they don't accept LT and RT OR modifier 50. Next step is to submit 64612 (2). Surely there should be some way to find out HOW we are to bill this and whether or not it's just a case of carrier preferences and accept the minor reduced payment from what other carriers follow?

---Suzanne E. Byrum CPC

 

[mitchellde]

64612 cannot be submitted with units greater than 1. The code specifies multiples in the descriptor it states muscle(s) in the descriptor.
Also for bilateral (50) and use of RT or LT modifiers, it must be for a procedure performed on a defined bilateral body part or organ. Muscles of the face are not defined as bilateral.
So no matter how many injections given, when of the same area in this case face then you may bill only one code with one unit. If the (s) were not part of the descriptor, you would use the 59 modifier.
In a CPT Assistant newsletter in 2001, the American Medical Association's CPT Information Services indicated that "codes 64612–64614 should be reported only one time per procedure even if multiple injections are performed in sites along a single muscle or if several muscles are injected."
another source states:
While multiple injections may be performed in sites along a particular muscle and several muscles are typically injected, only one unit of the appropriate CPT code (64612-64614) should be reported. Some payers do allow billing in multiple units or with a modifier (-50 to indicate bilateral limb injections, for example) but this is technically incorrect coding and could expose physicians to allegations of fraud and abuse.
I hope this helps you.

 

[ollielooya]

Deborah, thank you for your valuable input. That is the reason given by the carrier "...muscles of the face are not defined as bilateral and that it must be for a procedure performed on a defined bilateral body part or organ" And yes, I have seen those articles you mentioned. But there seems to be shades of grey for I've also seen articles (one by the American Association of Neurology for allowance of the bilateral billing with modifier 50, but what has caused me to stumble is the CMS policy guideline along with our local BCBS carrier allowing for bi-lateral billing. And as far as billing units (which I had read in the above article), it was actually the suggestion from one of the folks from customer service, and again, that didn't seem right to me. Still it seems to be carrier specific, and even if it is "technically incorrect coding" could it be said that the carriers are actually incorrect in their bilateral assignment policies? Following thru with this.... we would be in the awkward position of not "accepting" their policy citing CPT Assistant to over-ride carrier policies? This is certainly an unenviable position to be in.

Also concerning your "another source"---Would you mind sharing what/where that might be as I would love to follow up on it.

Ultimately it goes back to the bi-lateral billing and and need to get that statement in writing, "It must be for a procedure performed on a defined bilateral body part or organ. Muscless of the face are not defined as bilateral. Is it soooo obvious that I'm utterly missing it?

Thank you for taking time on a Saturday to help! ---Suzanne

 

[mitchellde]

The other source is Gina Gjorvad from the American academy of Neurology.
The definition of bilateral comes from basic anatomy.
And the code itself states "Muscles(s)" this in and of itself says the code is billable only once per site regardless of the number of muscles injected. It is possible that prior to 08 this code was a single muscle injection and since that time the descriptor was changes with addition of the (s) to make it multiple. You cannot change the definition of the code nomenclature.