Anesthesia Coding Alert

But don't forget -LT and -RT as possible options

Physicians perform many pain management procedures bilaterally, which means they treat both sides of the affected area during the procedure. Checking these four documentation points will help you determine whether adding modifier -50 (Bilateral procedure) to the claim is appropriate - and an easy way to boost your bottom line. Make Sure That Bilateral Coding Is Appropriate Your first checkpoint for bilateral reimbursement is whether the procedure code permits it. Most CPT codes represent unilateral procedures, but that doesn't mean you automatically report modifier -50 if the physician performs the procedure on both sides of the patient.

Some CPT codes distinguish between unilateral and bilateral procedures, so start by checking the descriptor. Keep these tips in mind when checking the codes:
  Some procedures have separate codes for unilateral and bilateral sessions. If CPT includes a bilateral code, report it rather than the unilateral code with modifier -50.
  Some codes represent bilateral procedures even if the descriptors don't state it. These primarily apply to some surgical procedures (such as 21193-21196 for procedures related to Reconstruction of mandibular rami) rather than pain management, but it never hurts to verify what services the code includes.
  Some procedures involve administering a block at one site and prepping another area for the same procedure. This means the physician either treats additional levels or performs a bilateral procedure, so verify the procedure so you can append modifier -50 if necessary.

When does modifier -50 commonly come into play for pain management? The most common scenarios are for injections such as:

27095, Injection for hip arthrography; with anesthesia

27096, Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

64400-64450, selective nerve root blocks
  64470-64476, facet injections
  64479-64484, transforaminal injections

64600-64681, somatic or sympathetic nerve destruction by a neurolytic agent (such as radiofrequency). "The problem when you're coding for facet or transforaminal injections is that you have codes for first level and additional levels," says Robin Fuqua, CPIC, anesthesia coder for Jose Veliz, MD, in Escondido, Calif. "We believe that even if you're on one level when performing bilateral injections, you should still bill the case as a first-level and additional-level injection. Then we add -LT (Left side) or RT (Right side) to indicate the side being treated."

Other coders agree with this approach, saying that it's always important to indicate clearly the physician's services when bilateral modifiers come into play.

Example: The physician administers three blocks to the right of L3, then later administers three more blocks to the left of L3. Many carriers approve a maximum of three blocks per level. If you don't clearly document that the physician treated both sides of the joint, the carrier might think he administered [...]