Otolaryngology Coding Alert

Although otolaryngologists generally do not perform middle-ear repairs on both ears on the same day, they  may do so to spare the patient a second surgery. Otolaryngologists who submit orderly documentation and append modifier -50 (bilateral procedure) to the appropriate tympanic repair code are paid for both sides.
 
The Physician Fee Schedule, however, states that none of these procedures is paid at a higher rate when performed bilaterally. The schedule is an authoritative document that provides the national payment framework for all Part B carriers, including the relative values of every CPT and HCPCS code, as well as code-specific payment instructions regarding global periods, multiple procedures, co-surgery and bilateral surgery.
 
Note: Access the Medicare Physician Fee Schedule at www.hcfa.gov/medicare/pfsmain.htm, click on "2002 National Physician Fee Schedule Relative Value File," click on file RVU02_a.zip and follow the prompts to download it. The easiest format in the zip package for viewing the fee schedule is pprrvu02.xls, which requires Excel or an Excel viewer. Other files in the zip package include the appendix that explains the meaning of each indicator in every field.
 
The appendix adds that "the bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure."
 
In the case of bilateral middle-ear surgery, neither A nor B applies, says Teresa Thompson, CPC, an otolaryngology coding and reimbursement specialist in Sequim, Wa.
 
"There is nothing about the physiology or anatomy of bilateral middle-ear surgery to disallow a bilateral adjustment," Thompson says. She says that none of the middle-ear repair descriptors list the procedures as bilateral and that she has not heard of any denials for these bilateral procedures.
 
Private payers are not obliged to follow the Medicare fee schedule: Most accept modifier -50, although some may prefer another billing approach. Many commercial carriers require that bilateral procedures be reported on two lines of the claim form: 696xx (repair) and 696xx-50. When billing Medicare carriers, the most prudent approach is to code each side separately and append modifier -59 (distinct procedural service) to the second code: 696xx and 696xx-59.
 
Note: Most Medicare carriers require a one-line approach for bilateral claims, with modifier -50 appended to the single code listed when billing for permissible bilateral services.