Billing for breast reconstruction

ajijon

Networker
Messages
35
Location
Morristown, NJ
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I wanted to ask you guys if you have noticed when the doctor performs a bilateral surgery does the insurance pay more when your bill one line item with the bilateral modifier versus billing two line items of the same procedure with mod 51 on the second line item. What is the proper way of billing??:confused:
 

nsteinhauser

Expert
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334
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For instructions on when to use laterality modifiers (-RT and -LT) on separate lines vs. one line with the bilateral modifier (-50), you need to find out what the specific payer wants. Look (hopefully you can read it online) at the 'provider manual' for that specific payer. It will tell you how they want the coding of multiple surgeries done and (hopefully) address how they want bilateral surgeries coded. And it should specify how they reimburse for such.

It may have been a fluke and/or adjudication mistake if you see different amounts allowed depending on your one -line or two-line billing of bilateral procedures. They should be consistent. Call the payer and see what you can find out.

Besides the -rt/-lt and -50, some payers don't want the -51, some payers want a -59, etc. It's a lot of minutiae to keep track of but your revenue depends on it.

Hope this helps.
 

jhartung

Networker
Messages
26
Location
Adirondack Chapter of Professional Coders, Glens F
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I would always bill bilateral breast reconstruction with a modifier 50 because the coding guidelines in the Ingenix Coding Expert state that if the procedure is done on both breasts to use modifier 50 rather than RT and LT. However, some payers are specific in the way they want it billed and do want the RT and LT. In that case, I would use modifier 59 and not 51, since 59 denotes a separate site being operated on and 51 only describes that multiple procedures are being done and is not as specific. Whichever way you code it, you should always remember that you are not coding to try and increase reimbursement, you are following coding guidelines and coding correctly from what is documented!!!
 
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