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Leorah Posted Fri 16th of June, 2017 02:41:59 AM
Hi, I am noticing that when I have 2 codes with a 50 modifier, for example a 36224(50) and then a 36226(50) the primary code 36224 will be paid at 150%(100% for primary and 50% for the additional) and the 36226 with the 50 modifier are paid two different ways. 1) will sometimes be paid at 75%(50% first and 25% for the second) 2) sometimes paid 100% (50% first and 50% second). Do you know which way Medicare and Medicaid follow? Thank you, Lee
SuperCoder Answered Mon 19th of June, 2017 02:52:00 AM

Hi,

Kindly consider the following link for referral :

https://www.cms.gov/Medicare/Medicare-Contracting/ContractorLearningResources/downloads/ja6526.pdf

Hope this helps!

Leorah Posted Mon 19th of June, 2017 06:06:56 AM
Thanks for your help. This link describes rules of modifier 50 by CMS. Can I assume that if Medicare considers a code to be eligible for 150% when coded with a 50, then Medicaid would agree? Thank you
Leorah Posted Mon 19th of June, 2017 17:03:48 PM
I was looking over this link that you sent and I just don't understand from the site when 150% is paid and when not. Could you please explain it in your own words? Thank you so much
SuperCoder Answered Tue 20th of June, 2017 02:54:37 AM

Hi,

The bilateral surgery payment policy indicators on the MPFS to determine if the 150 percent payment adjustment is payable for a specific Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) code.

A) For payment policy indicator 0 : code descriptor should specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

B) For payment policy indicator 2 : code descriptor should state that the procedure is bilateral, the codes descriptor state that the procedure may be performed either unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure.

For Payment Policy Indicator 1, the 150 percent payment adjustment for bilateral procedures does apply. The policy indicators apply to both medicare and medicaid.

Hope this helps! 

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