2020 Facet Joint Injection charging changes

Ringo3769

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I am hoping for guidance on how to bill out the facet joint injection add on codes when performed bilaterally. Previously the charges were submitted as a single line, 1 unit with modifier 50, but the 2020 guidelines have changed stating the modifier 50 is no longer allowed on the add on codes and if performed bilaterally, the CPTs are submitted as separate line items on the claim. Our claims scrubber is flagging this as exceeding the MUE for the add on codes.
From AMA CPT 2020:
“For bilateral paravertebral facet injection procedures, report 64490, 64493 with modifier 50. Report add-on codes 64491, 64492, 64494, 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495.”

There has also been an update to the modifier 50 guidelines in Appendix A on page 809 of the CPT book:
“Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. NOTE: This modifier should not be appended to designated “add-on” codes (see Appendix D).”

So on the UB, we would we charge 64493-50x1; 64494x1, 64494x1 and overrided the MUE edit on the scrubber?
Thank you!
 

bdcoyne8

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Jumping on as we are a Pain and Spine specialty clinic and we have no clue how to bill for these either. All of them are being held. Yay...

We have tried billing it as the 64493-50, 64494, 64494; 64493-50, 64494-lt, 64494-rt, and 64493-50, 64494-lt/rt. We are still waiting to see how they are reimbursed but this is absolutely crazy to me! Why change something that wasn't broken... Booo!
 
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I have billed it the new way per CPT (64490 50 64491 RT 64491 LT...) and just received denials from Medicare and United Health Care. They paid 64490 but denied the rest for exceeds # of services. I am going to send in corrected claim with modifier 50 until they adopt the new changes.

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management
 
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This seems to be a mess everwhere and is causing alot of headaches. Following along to see if we can gain any insight as well....................
 
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bdcoyne8

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I have billed it the new way per CPT (64490 50 64491 RT 64491 LT...) and just received denials from Medicare and United Health Care. They paid 64490 but denied the rest for exceeds # of services. I am going to send in corrected claim with modifier 50 until they adopt the new changes.

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management

Did you try the 64491RT and LT on the same line or do two lines with the RT and the LT? Thanks!
 

ReignRuby

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I have billed Medicare as below and received reimbursement for 64493. CPT 64494 is an add on code. Medicare will not pay these. Medicare wants RT and LT on two separate lines. Commercial is according to contract. Indiana Medicaid uses the 50 modifier for bilaterals. :)

64493- RT
64493 -LT
64494 -RT
64494 -LT

Valerie Tucker, CPC, CASCC
Goshen Health Surgery Center
 
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bdcoyne8

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there will not be modifier on add on code so no question to have modifier on add on code.
I don't know what you mean by that. There has to be a modifier as it's a unilateral procedure and needs to be indicated if LT/RT or Bilateral. The book instructs we can't use modifier 50. It does not state we can't use any modifiers.
 

Lugoves

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I wrote NCCI and CMS as neither the MUE or bilateral indicators have been updated in 2020 to reflect the AMA guidelines and this was there response. [My Query far below]


Thank you for your inquiry regarding the National Correct Coding Initiative (NCCI) program. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.



In your correspondence, you asked for a clarification on reporting paravertebral facet joint in injections, CPT Add-On codes 64491, 64492, 64494, and 64495, because the AMA CPT bilateral reporting instruction changed in 2020 for these procedures. Specifically, you asked about reporting CPT codes 64491, 64492, 64494, and 64495 with modifier 50.



We discussed your correspondence with CMS. Following this discussion, CMS has decided to retain the current MUE Practitioner (PRA) and Outpatient Hospital (OPH) Values.



For your convenience, you may use this hyperlink to access information regarding MUEs and Bilateral Surgical Procedures CMS MLN SE1422. The article provides details and examples for providers who perform bilateral surgical procedures for Medicare beneficiaries.



CMS and the NCCI Program appreciate your time in making this inquiry.



Sincerely,


Capitol Bridge, LLC

National Correct Coding Initiative Contractor

Email: NCCIPTPMUE@cms.hhs.gov

P.O. Box 368

Pittsboro, IN 46167

SBA Certified 8(a) Small Disadvantaged Business

This was my initial Query...
Good Afternoon,
The AMA included new instructions for CPT 2020 indicating the 50 modifier should no longer be reported with add-on codes as defined by the 2020 code set. The AAPC indicated their interpretation led them to believe RT/LT modifiers would be reported in those instances. Thorough review of our MAC website First Coast Service Options as well as the Medicare Claims Manual and NCCI edits do not address this. We received MUE denials on add on codes reported with anatomical modifiers for DOS on or after 01/01/2020. The AMA and AAPC were under the impression CMS was going to implement these changes. I see no change in the bilateral indicators from 2019 to 2020 on the add on codes pertaining to our Providers. Please advise.

Excerpt from 2020 CPT book
Modifier changes for bilateral Add On Codes
Bilateral Procedures for Add-On Codes
  • CPT 2020 includes new instructions for
reporting bilateral services for add-on codes
  • Modifier 50 is used for the primary code but
not for associated add-on codes
  • Add-on services reported bilaterally should be
reported twice and not by appending modifier
50
Bilateral Procedures for Add-On Codes
• Paravertebral facet injections lumbar two
levels performed bilaterally
• 64493-50
• 64494
• 64494
(For bilateral paravertebral facet injection procedures, report 64490, 64493 with modifier 50. Report add-on codes 64491, 64492, 64494, 64495 twice, when performed bilaterally. Do not report modifier 50 in conjunction with 64491, 64492, 64494, 64495)

Excerpt from MCM
If a procedure is performed bilaterally and the HCPCS code descriptor does not state that it is a unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) UOS. For specific instructions for Ambulatory Surgical Centers, refer to Chapter 14, Section 40.5 of the "Medicare Claims Processing Manual" at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf on the CMS website. When modifier -50 is required by manual or coding instructions, claims submitted with two lines or two units and anatomic modifiers will be denied for incorrect coding.

Excerprt from FCSO
Billing modifier 50 FAQ
Q: When is it appropriate to bill modifier 50?
A:
Modifier 50 is used to report bilateral procedures performed during the same operative session as a single line item. Do not use modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50.
When submitting claims for bilateral surgery, use modifier 50 with the procedure code. Modifier 50 applies to any bilateral procedure performed on both sides at the same operative session, except as indicated below. The bilateral modifier 50 is restricted to operative sessions only.
Modifier 50 may not be used:
• To report surgical procedures identified by their terminology as "bilateral," or
• To report surgical procedures identified by their terminology as "unilateral or bilateral," regardless of whether the procedure is performed bilaterally or not.
• When billing claims for procedure codes that are bilateral in nature, regardless of whether these services are performed unilaterally or bilaterally, providers should bill the surgical procedure code as a single claim detail line item without modifier 50.
• To report bilateral procedures furnished in ambulatory surgical centers (ASCs).
• Bilateral procedures performed in an ASC should be reported as either a single unit on two separate lines (appending the RT and LT modifiers) or with "2" in the units field on one line, in order for the bilateral procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting.
• Effective for services rendered on or after March 26, 2018, claims by ASCs inappropriately billed with a modifier 50 will be rejected.
Claims for bilateral surgical procedures should be billed on a single claim detail line with the appropriate procedure code and modifier 50 and one (1) unit of service (UOS).
To determine if a procedure should be billed with the modifier 50 as a bilateral procedure, providers may access the Medicare Physician Fee Schedule (MPFS) look-up tool. Select MPFS, enter the procedure code, date of service and locality. Once you select "Submit," the details relating to the procedure code will be revealed. Under the heading "Modifier," scroll to the “Policy Indicator” section. The "Bilateral Surgery" indicator will advise if a modifier 50 should be billed with the code.
For additional information, please access the Medicare Learning Network (MLN®) Matters® special edition article SE1422 .

Please use your browser's back button to return to the referring page.





Bilateral Status indicator.
 

Tcarter74

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I received the same response from Capital bridge- We asked specifically about billing 50 modifier for 64491 and 64494 when the new AMA CPT guidelines do not allow for billing 50 mod on add-on codes . They said that "We discussed your correspondence with CMS. Following this discussion, CMS has decided to retain the current MUE Practitioner (PRA) and Outpatient Hospital (OPH) Values." They suggested that we continue to bill these codes with the 50 modifier. This however creates confusion because we end up trying to separate Medicare patients and non-medicare patients to bill some insurances with 50 and some other insurances with LT/ RT. I would love to hear any feedback on how you are dealing with two separate sets of billing rules if you are in fact still using 50 modifiers for Medicare add on codes only.
 

Lugoves

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Thanks for the response and confirmation.

We just went back to previous methods for reporting bilateral on add-on codes with the modifier 50 for the payers that follow Medicare guidelines. The ones that don't we'll continue to indicate LT/RT as they preferred previously. We'll continue to monitor for future changes, and have advised our compliance department, who may or may not have additional input depending on any additional correspondence they are able to obtain from the AMA or CMS.
 

afelgner

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This is a tricky one and also frustrating. This is what I have been able to find in my search for answers to the same question; (please double check with your specific region and individual office managers)

With Medicare (J8) Indiana. They still have not updated their MUE's as of today, so it still shows an indicator of 1 for 64491/64492 and 64494/64495. On top of that these are still listed in the MPFS with a bilateral surgical indicator of 1. Per the CMS Modifier 50 Fact Sheet "When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule BILAT SURG indicator is 1: Report codes with a BILAT SURG indicator of 1 on one line, appending modifier 50 and submit one unit of service (NOTE: this differs from Current Procedural Terminology (CPT) Instruction.)

Using their rules and guidelines as of today's date it would appear that Medicare still wants them billed the old way:
64490-50
64491-50
64492-50

The 2020 Procedural Coding Expert also shows an MUE of 1 and the 50 modifier is listed for CPT 64491/64492 and 64494/64495 and it is marked as an Add On Code. (not sure if the book is missing updates since publication- I didn't see anything posted - did any one else?)

I would check with your compliance officer to see how they would like to proceed/handle this dilemma. Unfortunately, it sounds contradictory to CPT parenthetical guidelines.

Does any one else see the same information from CMS as I do?
 

StephCodes2

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We are experiencing the same. I work and code for HOPD, so our billing department is telling me that regardless of how we report it, the APC payment is the same. So, we're following the CPT Guidelines and reporting with RT/LT. At least for the time being. I do feel bad for our billing department, because I know this is creating problems on their end. But, the alternative is trying to figure out who will still accept 50 vs RT/LT.

I also wrote an appeal and received the very same comment as above.
 

kimlawson

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Thanks for the response and confirmation.

We just went back to previous methods for reporting bilateral on add-on codes with the modifier 50 for the payers that follow Medicare guidelines. The ones that don't we'll continue to indicate LT/RT as they preferred previously. We'll continue to monitor for future changes, and have advised our compliance department, who may or may not have additional input depending on any additional correspondence they are able to obtain from the AMA or CMS.
How has that worked out for you? We're about to attempt the same. Are you receiving payment? We are in Texas (not sure where you are). Please feel free to e-mail as I will see that much sooner. kim.lawson@mpm-med.com

Thanks,
Kim Lawson
 

Lugoves

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It works just as it has last year. We are in FL and GA and none of the Payers seem to have adopted the new bilateral policy for add on codes the AMA attempted to implement.
 

vanmarin

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There is also an indication on CPT +64492 and +64495 stating "Do not report 64492/64495 more than once per day", contradicting the instruction to report add-on codes 64491,64492,64494,64495 twice when performed bilaterally.
 
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