Otolaryngology Coding Alert

Verify modifier -50 use with fee schedule

Before you append modifier -50 to an ENT procedure, such as sinus surgery, tumor/cerumen removal or a hearing aid test, check the code's bilateral eligibility on the Physician Fee Schedule database or you could face improper code rejections and incorrect reimbursements. Look at 'Bilat Surg' Column To see whether a code qualifies for bilateral reporting, go to column "T," the bilateral surgery column of the National Physician Fee Schedule Relative Value File.

CMS assigns each CPT and HCPCS code one of five bilateral surgery indicators:
  0 - 150 percent payment adjustment for bilateral procedure does not apply ... due to physiology, anatomy or existing bilateral procedure code
  1 - 150 percent payment adjustment for bilateral procedure applies
  2 - 150 percent payment adjustment for bilateral procedure does not apply ... Medicare bases the code's RVUs on the physician performing the procedure bilaterally
  3 -The usual payment adjustment for bilateral procedure does not apply ...services are generally radiology services or diagnostic tests, which CMS does not subject to bilateral surgery payment rules
  9 - Concept does not apply. '1' Means -50 Is a Go If Medicare labels a procedure's "T" column (labeled "BILAT SURG") with a "1," you have a modifier -50 (Bilateral procedure) green light. When an otolaryngologist performs an identical procedure on both sides, you may report the code using modifier -50.

Example: An otolaryngologist performs bilateral total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]). When you look at 31255's column "T" designation, as well as all other functional endoscopic sinus surgery [FESS] codes 31233-31294, you notice a "1." So you may report 31255 with modifier -50.

Depending on your payer's preference, you may report a bilateral ethmoidectomy using one or two lines. Most Medicare carriers prefer that you list the code once with the bilateral modifier appended, says Susan Smith, CPC, billing supervisor at Otolaryngology Head & Neck in Milwaukee, Wis. Private payers may prefer you list the procedure twice and append modifier -50 to the second procedure only.

Payment: Most insurance companies reimburse bilateral claims at 150 percent of the code's assigned fee schedule amount. So you can usually expect about an additional $225 for a bilateral ethmoidectomy. Example: HGSA (Medicare Pennsylvania) pays 31255 at a participating rate of $478.02 and would reimburse a bilateral ethmoidectomy at $717.03. (For more on bilateral payments, see "You're Responsible for Modifier -50 Reimbursement".) '0' Negs -50, Permits Other Modifier Although finding a "0" in column "T" puts a stop on modifier -50, another modifier may describe the circumstances. Some possibilities that you may consider include:  modifier -51 - Multiple procedures
  modifier -59 - Distinct procedural service
  modifiers -LT (Left side) and -RT (Right side). Scenario: An otolaryngologist performs malignant tumor excision on [...]