Medical Billing Services

Using Correct Combinations – Modifier 50

One of the most frequent errors can result from the submission of invalid modifier combinations. In addition to​ the accurate coding of treatment, medical claims must be billed in combination with codes for additional services performed in the office, the corresponding modifiers, if necessary, and ICD-10 or diagnosis codes. In this article, we will be discussing wrong modifier combinations for modifier 50 (bilateral procedure).

Guidelines:

  • Do not submit CPT modifier 50 on procedures for midline organs such as the bladder, uterus, esophagus and nasal septum
  • If a (subsequent) bilateral procedure requires a return to the operating room after the initial surgery, and the bilateral indicator in the MPFSDB is 1 or 2, do not submit CPT modifier 50. CPT modifiers 50 and 78 cannot be submitted for the same service. Instead, submit the surgery procedure code with CPT modifier 78 and HCPCS modifier RT on one detail line, and submit the same surgery procedure code with CPT modifier 78 and HCPCS modifier LT on a separate detail line.

When modifier 50 is included in the medical claim, it can render certain other modifiers invalid (such as 26, LT, RT, and TC). Modifier 50 is only added to a medical procedure when that particular procedure is completed bilaterally, or on both sides.  Modifiers LT and RT refer to a procedure completed on only the left or right sides. Modifier 26 refers to the professional component of a service or the interpretation of such services. Modifier TC references the technical component of such service or the interpretation thereof.

  • Modifier 50 (Bilateral Procedures) is used to identify bilateral procedures during the same operative session.
  • Modifier 26 (Professional Component) is used to identify the professional component of a service performed by a physician or interpretation of the services performed by a physician.
  • Modifier LT (Left Side) is used to identify that the procedure is performed on the left side of the body.
  • Modifier RT (Right Side) is used to identify that the procedure is performed on the right side of the body.
  • Modifier TC (Technical Component) is used to identify the technical component of a service performed by a physician or interpretation of the services performed by a physician.
  • Indicator 0: The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator ‘0’ with HCPCS modifier RT or LT or CPT modifier 50. The submission of these modifiers may result in a denial. Payment will be based on the lower of the actual charge for both sides or 100 percent of the fee schedule amount for a single code. The bilateral adjustment is not appropriate for codes with Indicator ‘0’ because of (a) physiology or anatomy, or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for a bilateral procedure.
  • Indicator 1: The 150 percent adjustment for bilateral procedures applies. Bilateral procedures must be reported with CPT modifier 50 and a quantity of ‘1’. When the code is reported with CPT modifier 50, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other ‘multiple procedure’ rules. Submission of modifiers other than 50 may result in a denial.
  • Indicator 2: The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator 2 with HCPCS modifier RT or LT or CPT modifier 50. The Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charges by the physician for both sides or 100 percent of the fee schedule amount for a single code. If codes with bilateral indicator 2 are submitted with HCPCS modifier RT or LT or CPT modifier 50, the claim will be rejected as a ‘billing error.’ These claims must be corrected and resubmitted as new claims.
  • Indicator 3: The 150 percent adjustment for bilateral procedures does not apply. Payment will be based on the lower of 100 percent of the fee schedule for each side or actual charges for each side. Report bilateral procedures with CPT modifier 50 and a quantity of ‘2’ or report on separate detail lines with HCPCS modifiers RT and LT. Services in this category are generally radiology procedures or other diagnostic tests that are not subject to the special payment rules for other bilateral procedures.
  • Indicator 9: This indicator often appears in the CO SURG column for nonsurgical procedures.

There are a lot of wrong modifiers combinations like using modifiers 24, 25 or 59. We will be discussing those in our upcoming articles. Many of these invalid modifier combinations can be avoided if you have properly trained medical coding personnel. Another easy way is you can get connected with MedicalBillersandCoders (MBC) who have such experts. These coders are constantly trained to stay on the top of medical coding.  To know more about our medical billing and coding services you can call us at 888-357-3226 or write to us at info@medicalbillersandcoders.com

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