Wiki Retrogrades CPT 52005

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Jessim929

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Hi All!

When your docs are doing bilateral retrogrades - CPT 52005 - how are you billing them? MUEs are now 1 this year and I was taught that needed the -59 or XS/XU modifier. I have a case (which will become multiple) where I billed the bilat with the XU-RT and XS-LT mods and Medicare denied both and came back with remove the lateralities and bill one unit.

Before I get the explosion from my providers when I drop this bomb on them, I kinda want to know what others' experiences have been.

Thanks!!
 
I believe you were taught incorrectly. The Medicare bilateral indicator on this code, for as long as I've been aware, has been '0', which indicates that the code is not reimbursed as a bilateral procedure. Per the indicator's definition: "If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code." The second side should never have been separately paid if this was a bilateral procedure. So if you were reporting this with the 59/XS/XU modifier in order to bypass the normal payment rules and were getting away with it, then in my opinion, this was an error (and is also incorrect coding). I suspect that the change to the MUE was likely done to close this loophole. You should probably gather some additional opinions on this before acting, but I'd suggest that your providers should be made aware that if they were getting paid extra for these bilateral procedures in the past, this was likely a mistake and you may want to prepare them for the possibility that these overpayments may need to be refunded to Medicare.
 
I've been billing this code for 4 years and have only billed it as one unit, whether it's unilateral or bilateral.
 
I agree. Medicare will pay for unilateral or bilateral retrogrades with code 52005 and one unit in column/box 24G. Private or commercial carriers will pay for bilateral retrogrades with 52005-50 and one unit in column/box 24G.
 
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