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50 Modifier

Vera Posted Fri 04th of October, 2013 15:53:35 PM

RE: Medicare

For years I have billed RT.LT as modifiers when billing a bilateral procuedre - bilateral bunionectomy - or bilateral X-rays, etc... Suddely I got a surgery denied because they say to bill a 50 modifier for a bilateral procedure......I have been denied in the past using the 50 modifier, and now I am being told to use it.... If you call Medicare there is a different answer each call, depending on who answers the phone! What is the rule ? How should it be billed ? And what's the big deal between RT.LT and 50 ? They both MEAN THE SAME thing..... Frustrating. Thank you.

SuperCoder Answered Sat 05th of October, 2013 00:45:57 AM

Bilateral Procedure

Appropriate Usage
When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule Relative Value File (MPFSRVF) (also known at the Medicare Physician Fee Schedule Database (MPFSDB) BILAT SURG indicator is 1 or 3.
Report codes with a BILAT SURG indicator of 1 on one line, appending modifier 50 and submit one unit of service. (Note: this differs from Current Procedural Terminology (CPT) instruction)
Report Codes with a BILAT SURG 3
On one line appending either modifier 50 or RT and LT using one unit of service or
Submit on one line using two units of service or
Submit on two lines of service using RT on one line and LT on the other with one unit of service each.
When performing the procedure on bilateral body parts.
Inappropriate Usage
Reporting this modifier when performing the service on different areas of the same side of the body.
The BILAT SURG indicator is 0, 2, or 9.
When removing a lesion on the right arm and one on the left arm. Use the RT and LT modifiers.
On a procedure code that is described as bilateral or unilateral or bilateral in its CPT description.
Do not report a bilateral procedure on two lines of service appending modifier 50 to the second line of service.
Additional Information
Modifier 50 is used as a payment, rather than informational, modifier. The addition of this modifier could affect payment depending on the procedure code and the BILAT SURG indicator. Following are the indicators and their descriptions.

BILAT SURG indicator "0" - the 150% payment adjustment does not apply. When a procedure is reported with a modifier 50 or modifiers LT and RT base the payment for both sides on the lesser of the total charge or the fee schedule for a single code. For example, code XXXXX 50 is billed at $200. The allowed amount on a single code XXXXX is $125.00. Medicare will allow $125 for both services. Payment in full for both services is inappropriate because of physiology or anatomy, or the code description is for a unilateral code and a bilateral code exists.

BILAT SURG Indicator "1" - The 150% payment adjustment does apply. When the service is submitted with modifier 50, the LT and RT or with 2 units of service, then Medicare will allow the lower of the billed amount for both services or will allow 150% of the allowed amount for a single service. Medicare will allow the bilateral adjustment before the multiple procedure payment adjustment when the provider submits other services subject to the multiple surgery rules.

BILAT SURG Indicator "2" - The allowed amount is for a service performed bilaterally. Medicare could allow the lower of the actual charge or the fee schedule for a single service. The procedure code descriptor is bilateral, or unilateral or bilateral or the service is usually performed bilaterally. When billing for a procedure with a "2" indicator use one number of service and one line of service. Medicare will reject the services as unprocessable.

BILAT SURG Indicator "3" - The Medicare allowed amount is for 2 units of service. If the service is submitted using a modifier 50 or the RT/LT or two units of service, then Medicare will allow the fee schedule for both services. Apply the multiple surgery rules prior to applying the multiple payment reduction rules. Services in this category are generally radiology or other diagnostic tests and are not subject to the special payment rules for bilateral surgeries.

BILAT SURG Indicator "9" - The bilateral payment adjustment concept does not apply.

Additional Information
In general, the above information applies when two of the same procedure codes are performed on the same day for the same patient by the same provider or a member of the same group with the same specialty, there could be instances where two separate procedure codes are used. If so, Medicare's payment or denial would depend on any other type of rules and regulations concerning the individual services in question. This could include the National Correct Coding Initiative (NCCI) that could necessitate additional modifiers, duplicate edits, and global surgery edits.

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