Wiki Medicare & bilateral procedures

[hsheetz68]

I am having a real problem getting Medicare to pay bilateral procedures. When our office started billing for our ENT physician, I submitted bilateral procedures on two separate lines - one procedure code w/a RT modifier and the second procedure code w/a 76 and LT modifier. We had no problems with payment. Recently Medicare started denying our claims. Our AR clerk called and was told that Medicare wants bilateral procedures billed with one unit and a 50 modifier. My supervisor and I have been researching this problem and he actually found something from CMS stating that these procedures should be billed on separate lines w/a RT & LT modifier. Medicare is the only payor that we are having this problem with.

Our doctors are paid by RVU's billed so our concern about billing a bilateral procedure w/one unit & a 50 modifier is that they are only getting paid for doing a unilateral procedure.

Has anyone else had this problem?? Any help would be greatly apprecitated!!

Thanks!!

 

[MarcusM]

You most likely will have to appeal with documentation of the procedures with your reasoning based on your research why Medicare should pay you correctly. Cut and paste the CMS information that indicates you should bill on separate lines and if you have an outside source that also clearly states that you are billing correctly, and then have this letter as a template to appeal any future claims. I had to do this with right and left heart cath procedures years ago. Good luck.

 

[mrsstfuller]

Medicare does our bilateral procedures with a 50 but they make up for it by paying 150% of allowable. Which is same as them doing multi procedure reduction. check your reimbursement rate and make sure that is what they are doing for you

 

[mitchellde]

the MCM states bilateral must be billed with one line with a 50 modifier and 1 unit of service. You may be looking at a really old communication for the 2 line billing instructions. Check the new MCM.