Orthopedic Coding Alert

Realize $430 more for bilateral laminotomy with the correct modifier

You're not alone if you have difficulty distinguishing among modifiers -LT, -RT and -50. Fortunately, with the aid of the Medicare Physician Fee Schedule database and our experts'advice, you can select an appropriate modifier with confidence.

Before you decide between modifier -50 (Bilateral procedure) and modifiers -LT (Left side) or -RT (Right side) for a given claim, you should consult the 2004 Physician Fee Schedule database, which is available on the CMS Web site at www.cms.hhs.gov/physicians/ pfs/#2004.

If you find a "1" in column "T" (labeled "BILAT SURG") of the fee schedule database, you can append modifier -50 to the code.

Example: The orthopedic surgeon performs a bilateral lumbar laminotomy (63030, Laminotomy [hemilaminecto-my], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]).

When you find 63030 in the Physician Fee Schedule database, you'll notice a "1" in column T, and you can therefore report 63030-50. Because most payers reimburse bilateral claims at 150 percent of the assigned fee schedule amount, you can expect an additional $430 for this procedure (for a total payment of $1,290, based on national average payment using 2004 fee schedule figures).

"Depending upon payer rules, you will either have to list the procedure twice and append modifier -50 to the second procedure or only list the code once with the bilateral modifier appended," said Deborah Berry, CPC, during her presentation, "Modifiers, the Key to

Reimbursement," at the American Academy of Professional Coders'2004 national conference in Atlanta.

A "0" in column T tells you that you cannot use modifier -50. You may report modifiers -LT or -RT, however, either in combination or singly, to enhance your claim's specificity.

Example: Tendon sheath and trigger point injections (20550-20553) contain a "0" in column T, meaning you should not append modifier -50 to these procedures. But if the orthopedic surgeon administers several injections to the right wrist and several more to the left wrist, you can report the injections using 20550-RT (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) and 20550-LT.

If you simply report 20550 x 2, payers might reject the second unit as a redundant (repeat) procedure. By specifying -RT and -LT, you clearly demonstrate injections to two different anatomic locations.

Note: To further demonstrate the separate nature of the injections sites, you should also append modifier -59 (Distinct procedural service) to the second unit of 20550.

CPT added the anatomic-specific modifiers -RT and -LT "to streamline the claims processing system, to allow for automated payment without having to request additional documentation to rule out duplicate or other inappropriate billing," according to the January 2000 CPTAssistant.

If you don't find a "1" or a "0" in the fee schedule database's column T, you should append neither modifier -50 nor modifiers -LT/-RT. A"2" in column T of the database indicates that the code already specifies a bilateral procedure, so you should not append a modifier to denote a bilateral procedure. Often, such codes will also specify "unilateral or bilateral" in their CPT descriptors.

Example: CPT code 63045 specifies, "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [e.g., spinal or lateral recess stenosis]), single vertebral segment; cervical." Because the descriptor states that the procedure is either unilateral or bilateral, you know that payers will consider modifier -50 irrelevant.

Further, the Physician Fee Schedule database assigns this code a "2" in column T. So, if the orthopedist performs a bilateral cervical laminectomy, you should report a single unit of 63045 with no modifiers, says Tiffany Schmidt, JD, policy director for the American Association of Electrodiagnostic Medicine.

If column T includes a "9," the concept of bilateral surgery does not apply to that code. Therefore, you should never claim modifier -50 or modifiers -LT/-RT in combination for that procedure. Orthopedic practices will rarely encounter such procedures.

Example: The Physician Fee Schedule database assigns a "9" to 22841 (Internal spinal fixation by wiring of spinous processes). An orthopedic surgeon who performs this procedure should report a single unit of 22841, regardless of the location of the processes he wires.

When dealing with non-Medicare payers, you should ask your insurers how they advise you to report modifiers -50 and -LT/-RT. Not all private payers follow CMS guidelines: Some insurers will specify when they prefer modifier -50 and when they require modifiers -LT/-RT. Other payers prefer modifiers -LT/-RT in all circumstances because they think those modifiers are more specific than modifier -50.

Protect yourself: Always be sure to get the payers' coding recommendations and payment guidelines in writing to protect yourself in the event of audits or insurance reviews.