Podiatry Coding & Billing Alert

For clues, look to the numerical indicator in Column T of the fee schedule.

Deciding when to apply modifiers 50, LT and RT is a puzzling task if you have no idea how to select the appropriate modifier with confidence. Your decision-making should follow a combination of tried and tested advice from CMS, CPT and coding experts. Let these 3 tips guide you.

Tip 1: Know the Ins and Outs of Using Modifier 50

When the physician performs procedures on both sides of the body during the same operative session or on the same day, then you know he's rendering bilateral services. Modifier 50 (Bilateral procedure) doesn't apply to procedures that are bilateral by definition or described as "bilateral" or "unilateral".

More specifically, CPT defines modifier 50 as: "Bilateral Procedure: Unless otherwise identified in the listing bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five digit code."

Example: The podiatrist administered an injection of 10 mg Kenalog each on both feet. You should bill J3301 (Injection, triamcinolone acentonide, not otherwise specified, per 10mg) just once. You need to append modifier 50 since the physician injected Kenalog on identical anatomic sites.

Quick fact: Modifier 50 should follow the procedure code in Item 24d of the CMS-1500 claim form, or in the equivalent electronic field, when services are rendered bilaterally. You should use this modifier to report diagnostic, radiology and surgical procedures.

Payer preferences vary on the usage of modifiers 50. Most Medicare carrier payers prefer that you list the code once with the bilateral modifier appended (e.g., J3301-50), says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. Just, the same, some payers would want you to list the procedures twice and append modifier 50 (e.g., J3301, J3301-50).

Don't forget that when reporting J codes, the number of drug units injected by the physician plays an important role to coding. Also, the physician should clearly document the amount of the drug injected and the specific area injected. If there's any unavoidable wastage, the physician should include in the documentation the specific amount wasted. You will report the wasted amount using modifier JW (Drug or biological amount discarded/not administered to any patient).

Tip 2: Check Out Fee Schedule's Column "T"

One of the first places to look at to check the accuracy of your modifier 50 coding is Column T (labeled "BILAT SURG") of the fee schedule database. If you find a "1" in this column, you can append modifier 50 to the code.

However, if you find a "0" in Column T, it means you cannot use modifier 50. You may report modifiers LT (Left side [used to identify procedures performed on the left side of the body]) or RT (Right side [used to identify procedures performed on the right side of the body]), either in combination or singly, to make your claim more specific.

Example: A podiatrist performed incision and drainage of the bursa on each foot during the global period for open treatment of metatarsal fractures in both feet. You would report 28001 (Incision and drainage, bursa, foot) to describe the I&D. Coding it twice, you would append modifiers 79 (Unrelated procedure or service by the same physician during the postoperative period), and LT/ RT to indicate the location of the procedure. Your report would look like this: 28001-79-LT and 28001-79-RT. You should notice that 28001 has "0" in Column T of the fee schedule database.

Warning: Do not use modifiers RT and LT when modifier 50 applies. Why? Modifier 50 indicates left and right already therefore you would not double-report it by using LT/ RT, explains Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va.

Tip 3: Indicators "2" and "9" Say Something

A numerical indicator of "9" in Column T of the fee schedule means the concept of bilateral procedure doesn't apply to that code. In this case, you should never claim modifier 50, LT and RT in combination of the procedure.

A "2" in Column T indicates that the code already specifies a bilateral procedure, so you don't have to append a modifier to denote a procedure's bilateral nature. You would usually see the terms "unilateral" or "bilateral" in the CPT descriptors.

Safety net: Since payers have different policies on how they would want coders to report modifiers 50, LT and RT, you should always get your payer's recommendations -- preferably in writing -- to protect yourself from possible audits.