Otolaryngology Coding Alert

Question: Do the rules for Medicare's resource-based relative value system (RBRVS) mean that an insurer should pay 150 percent of the global amount for a bilateral procedure, such as 69436-50?

Michigan Subscriber
 
Answer: Based on Medicare's modifier -50 (Bilateral procedure) definition, carriers should reimburse the primary surgery code at 100 percent of the procedure's relative value units (RVUs). The insurer would then halve the bilateral procedure's RVUs and pay the second operation at 50 percent. Thus, Medicare would pay 150 percent of the global fee.

For instance, the 2004 National Physician Fee Schedule Relative Value File assigns 4.35 RVUs to 69436 (Tympanostomy [requiring insertion of ventilating tube], general anesthesia). Medicare carriers usually prefer one-line bilateral reporting, so you should report 69436-50 to indicate a bilateral procedure, and calculate 150 percent of 69436. You would submit the claim as follows:

69436-50 at $243.64 ([4.35 RVUs x $37.34 conversion factor] x 150 percent).
 
Note: These reimbursement figures represent Medicare's Physician Fee Schedule payment amount, unadjusted for geographic region.
 
If a payer reduces reimbursement to 100 percent, you should break the claim into two lines and include a fee for each, as follows:

69436 at $162.43 (4.35 RVUs x $37.34 conversion factor)
69436-50 at $81.21 ([4.35 RVUs/2] x $37.34 conversion factor). Some experts recommend that you append body-side modifiers to indicate where the tympanostomy occurred. Modifiers -LT (Left side) and -RT (Right side) don't affect reimbursement, but they give the insurer additional information. If, for example, the otolaryngologist performs tympanoplasty with ventilating tube insertion under general anesthesia, you may report the following codes:

69436-LT         $162.43
69436-50-RT    $81.21. If the insurer still doesn't reimburse the bilateral procedure, you should appeal. Include a copy of Medicare's fee schedule, which proves that Medicare pays a code's fee schedule amount at 150 percent if the code contains a bilateral indicator of "1" -- and 69436 does. -- Answers to You Be the Coder and Reader Questions provided by Andrew Borden, CCS-P, CPC, CMA, department of otolaryngology and communication sciences reimbursement manager at Medical College of Wisconsin in Milwaukee; Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.; and Darlene Reed, CPC, certified coder for Northland Ear, Nose and Throat in Liberty, Mo.