Wiki laterality modifiers

[melinda36]

Anesthesia provider here...If you have pain block or multiple pain blocks, if a provider leaves off laterality on the block, or puts on one but leaves off the second, do you add since the intent and op note states? Or do you inquire with provider to add modifier?
Inquiring because our rules require us to have the provider add laterality before we send out government claims. Is it necessary to hold out claims while we wait to see IF they add it, when we can basically prove what side?

 

[iowagirl77]

Anesthesia provider here...If you have pain block or multiple pain blocks, if a provider leaves off laterality on the block, or puts on one but leaves off the second, do you add since the intent and op note states? Or do you inquire with provider to add modifier?
Inquiring because our rules require us to have the provider add laterality before we send out government claims. Is it necessary to hold out claims while we wait to see IF they add it, when we can basically prove what side?

From a coding perspective, if the documentation states the laterality I would add the appropriate laterality modifier, assuming it is an option for that CPT. If you have internal policies though that state you need the provider to make the change or approve the change, then you'd need to go by your internal policy before making changes.