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.