50 Modifier reimbursement on + on codes?

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Hello, can any experts help clarify what is correct reimbursement for this situation? We are billing bilateral pain management injections and the insurance is paying the + on levels @ 200% of the single rate instead of the 150% we thought to be correct. Please see below example:

CPT 64490 50 mod- they are reimbursing @ 150% of the single rate;
CPT 64491 50 mod- they are reimbursing @ 200% of the single rate;
CPT 64492 50 mod- they are reimbursing @ 200% of the single rate;

Is there a CMS guideline/policy be provided to me to advise if these add on codes billed bilaterally should be reimbursing @ 150% or 200%?
 

vanessamoldovan

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Local Chapter Officer
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Hello, can any experts help clarify what is correct reimbursement for this situation? We are billing bilateral pain management injections and the insurance is paying the + on levels @ 200% of the single rate instead of the 150% we thought to be correct. Please see below example:

CPT 64490 50 mod- they are reimbursing @ 150% of the single rate;
CPT 64491 50 mod- they are reimbursing @ 200% of the single rate;
CPT 64492 50 mod- they are reimbursing @ 200% of the single rate;

Is there a CMS guideline/policy be provided to me to advise if these add on codes billed bilaterally should be reimbursing @ 150% or 200%?
 

thomas7331

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200% would be correct for an add-on code billed bilaterally. Because add-on codes are always billed in conjunction with another procedure, the multiple procedure reductions are already built in to the pricing and those codes are not reduced again under standard multiple procedure payment policy (essentially the payment rate for an add-on is already at 50%). The primary code will pay at 150% (100% for the initial side and 50% for the second side) but the add-ons will pay 100% for each side because no additional reduction would apply to the second side.
 

lburns23

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In the new CPT 2020 book, it now says "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."

I had to go check my 2019 book and it does not say that, so it must be a new change. But now I'm wondering if we have to put the LT & RT modifiers on each of the add-on codes, or do we just bill 2 units? Any ideas?
 
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