Wiki New Facet Codes with Medicare

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bella2

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Hi,
I've a quick question, when coding bilateral procedures I normally use a RT and LT modifier but for codes 64492 and 64495 in the CPT it states to only report those codes once per day. I tried to use the RT/LT modifiers and recieved a pop up from 3M Encoder staing not to uses these codes more than once per day. Should we go back to using a 50 Modifier.

Any insight would be greatly appreciated.
Thanks,
Bella
 
Unfortunately this is not an answer. I just came up with the same question. We use Custom Coder and there are no modifiers listed for the facet codes. Are they now to be treated like epidurals and don't get separate coding by LT/RT?
 
Medicare still requires ASC's to bill bilateral procedures using LT and RT, so go ahead and override that pop up and bill it on two separate lines.
 
I agree with Walker. The coding programs we use (I use Encoder) do not take into account the ASC rules. I would override and bill accordingly.
 
Not a problem overriding the LT/RT, but what about the statement that 64492 and 64495 are only to be billed once per day. What do you do in this case when you have bilateral injections, 3 levels each?
 
I think what they meant is that you aren't to bill those codes once for the third level and again for the fourth level. In the case of Medicare ASC's, when you bill 64495-RT & 64495-LT, you are really only billing one level after all, so you aren't really violating the directive.

ASC three levels bilateral for Medicare:

64493-RT
64493-LT
64494-RT
64494-LT
64495-RT
64495-LT
 
If it makes you feel better, you can also code it like this:

64493 x 2 units
64494 x 2 units
64495 x 2 units

There hasn't been any directive from Medicare specifically regarding how to bill the new facet codes in an ASC. Without that, you must default to the standard way of billing bilateral procedures, which are the two scenarios described above. I'm sorry I couldn't provide any documentation. If I come across some, I will post it here.
 
mbort said:
which documentation are you looking for--the codes only billable once per day or to use RT/LT and that 50 is not a payable modifier in an ASC??
Click to expand...

I think Bella is (understandably) having difficulty reconciling Medicare's bilateral procedure directive with the CPT guidelines for codes 64492 and 64495, which says to bill them only once per day.
 
Thanks everyone for taking the time to respond to my question, this is such a wonderful group of people on this forum :)
For now I'm billing out the bilateral injections for Medicare with the RT/LT modifiers, and all other commercial payers by the CPT guidelines.

Thanks again to everyone for responding,
Cheers,
Bella
 
64490-64495 bilaterally

I am dying here, attended conference in Orlando, that clearly states to use the 50 Modifier on bilateral injections and now no one is paying HELP, I dont feel the RT and LT are correct>>>:eek:
 
Use of New Facet Injection Codes for 2010 Written by Paul Cadorette CPC, CPC-H, CPC-P, CEDC, COSC, CASCC | Tuesday, 12 January 2010 22:10 | More Tags: CPT 20550 | CPT 64490 | CPT 64493 | CPT 64999 | mdStrategies

Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.

CPT copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

1. Report one code per level, but you can only report up to three levels. When documentation reads injection at C5-C6 and C6-C7, two levels are represented, so report CPT codes 64490 and 64491. When the documentation reads injection at C5, C6 and C7 (medial branch blocks) that would be three different levels reported with three CPT codes 64490, 64491 and 64492.


2. CPT code 64492 and 64495 represent third and any additional levels so you would NEVER report more than three facet injection codes for cervical/thoracic or three facet injection codes for lumbar/sacral regions.

3. Fluoroscopy or CT guidance are considered components of the CPT code so these types of image guidance would not be additionally reported, BUT USE OF FLUOROSCOPY OR CT IS REQUIRED TO ACCOMPLISH THE PROCEDURE – SO, IF IMAGE GUIDANCE IS NOT USED YOU WOULD REPORT 20550-20553.

4. Parenthetical notes in the CPT book are incorrect — they state if ultrasound guidance is used report 64999. THIS IS WRONG. When ultrasound guidance is used report the appropriate Category III code from the 0213T-0218T range. These codes are not listed in your CPT book but can be found on the AMA Website. http://www.ama-assn.org/ama/pub/phy...urance/cpt/about-cpt/category-iii-codes.shtml

5. Facet Injections performed at the T12-L1 level should be reported with CPT code 64493 LUMBAR — this differs from CPT Assistant guidance that tells us to report 62310 (cervical/thoracic) when an epidural injection is performed at T12-L1. (Dec. 05 Special Issue Q&A)

6. Although the codes have changed you can still report bilateral procedures with modifier -50 or RT/LT as appropriate.
 
The above post notwithstanding, Medicare contractors will NOT accept mod-50 on a claim coming from a facility. They want you to use the left and right modifiers instead. Professional claims should use the mod-50.
 
lgentry said:
I do believe that it reports -50 or RT/LT AS APPROPIATE
Click to expand...

I must disagree. I will quote Medicare:

"Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one line, in order for both procedures to be paid. While use of the -50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting."

Here is the complete article:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0742.pdf
 
I am not disagreeing with you. I am saying that use 50 for private and lt and rt for Medicare. "As Appropriate" to me means just that if you have Medicare code what is appropriate for Medicare if you have private code 50 or LT/RT however they process the claim.:) Its all good!
 
How would you bill facet injection (to commercial insurance) performed at, as an example; to L3/L4 and L4/L5 bilateraly?
is this correct?


64493.50 (2 units)
64494.50 (2 units) or

64493.50 (1 unit since we are billing modifier 50)
64494.50 (1 unit)


Thank you for your help

Jesenka
 
Hi

At my ASC, we bill everybody by Medicare guidelines (RT/LT), unless otherwise specified in payor contract, There is a section in the ACS claims processing manual, i believe, on the CMS Website, that will explain the bilateral requirement of RT/LT.

That being said, Unless the commercial contract states specifically how to bill we follow Medicare guidelines. I know that our WC requires RT/LT as well as the majors...Aet/Bcbs/Cigna/UHC...etc...

I will search for the link and post back to you..have a nice day!!:)
 
Billing Bilateral Procedures/Medicare

Here is what i found...

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0742.pdf in case this link is dead: try this: MLN Matters Number: SE0742 Revised

Billing Bilateral Procedures:
Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one line, in order for both procedures to be paid. While

MLN Matters Number: SE0742 Related Change Request Number: N/A

use of the -50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting.
The following provides a hypothetical example that illustrates this payment policy:
Correct Reporting
Example
HCPCS
Description
PI
Units
ASC-Reported Charges
Unadjusted Medicare Payment Rate*
Unadjusted Medicare Payment* to Provider with Multiple Procedure Reduction
Unadjusted Beneficiary Payment* to Provider with Multiple Procedure Reduction
15823
Revision of Upper Eyelid
A2
1
$1,000
$800
$800 x .80 = $640
$800 x .20 = $160
Claim 1:
Bilateral Procedure Reported on Two Lines
15823
Revision of Upper Eyelid
A2
1
$1,000
$800
($800 x .50) x .80 = $320
($800 x .50) x .20 = $80
Because the provider reports the bilateral procedure on two separate lines, and because the multiple procedure reduction applies to 15823, the provider receives total unadjusted payment (from Medicare and the beneficiary) of $1,200 for both procedures.
Claim 2:
Bilateral Procedure Reported on One Line with Two Units
15823
Revision of Upper Eyelid
A2
2
$2,000
$800 X 2
[$800 + ($800 x 0.50)] x .80 = $960
[$800 + ($800 x 0.50)] x .20 = $240
Because the provider reports the bilateral procedure using “2” in the units field, and because the multiple procedure reduction applies to 15823, the provider receives total unadjusted payment (from Medicare and the beneficiary) of $1,200 for both procedures.
Incorrect Reporting
Claim 3:
Bilateral Procedure Reported on One Line with Bilateral Modifier
15823 50
Revision of Upper Eyelid
A2
1
$2,000
$800
$800 x .80 = $640
$800 x .20 = $160
Because the provider reports the bilateral procedure using the bilateral modifier, the provider receives total unadjusted payment (from Medicare and the beneficiary) of $800 for only one of the procedures.
 
64495 in ASC

tincyr said:
Not a problem overriding the LT/RT, but what about the statement that 64492 and 64495 are only to be billed once per day. What do you do in this case when you have bilateral injections, 3 levels each?
Click to expand...

We have to list it on two seperate lines 64495 on the first line gets the 50 and the 64495 on the second line has no modifier but in ASC side you have to list them seperately no RT and LT is acceptable for this procedure in the ASC and we are being paid accordingly.
 
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