Wiki MUE of 1 but a bililateral procedure

[Robbin109]

If Medicare has a MUE of 1 but the CPT can be billed bilaterally, can you bill this with a 50 modifier and get paid for both sides?

 

[Samantha.Prince]

Code?

What is the CPT code?

 

[Robbin109]

64561

 

[mhstrauss]

64561

64561 has a bilateral indicator of "1" on the RVU file, which means that bilateral payment does apply:

If the indicator is "1," the 150 percent payment adjustment for bilateral procedures applies. If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code. If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.

You should be able to bill this on one line with modifier 50. I think I read in one of your other threads about this topic, you said that Medicare doesn't "like" modifier 50, but we use it often (not on this particular code, but many others) with no problems; my MAC is Novitas.

HTH!

 

[Robbin109]

Thank you.

 

[nlbarnes]

Bilateral

So I'd like to chime in or ask a further question on this. When it's a payment indicator of 0, I thought BOTH codes, 15734, get paid at 100% as it's not subject to payment adjustment. I'm reading the description from CMS but am doubting myself now.

 

[mhstrauss]

So I'd like to chime in or ask a further question on this. When it's a payment indicator of 0, I thought BOTH codes, 15734, get paid at 100% as it's not subject to payment adjustment. I'm reading the description from CMS but am doubting myself now.

No, bilateral indicator of "0" means that only 1 unit will be paid, even if billed with modifier 50, per the statement in the description "payment for the two sides will be based on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code."
Also (and I'm not familiar with this code, just thinking back to something I remember reading about skin in general), I don't think modifier 50 would be appropriate anyway, as skin is not a "unilater/bilateral" organ. If 2 separate trunk flaps are done, I think it would be more appropriate to bill on separate lines with modifier 59 or the appopriate X- modifier. Hopefully someone with more experience with this will chime in.

 

[nlbarnes]

Bilateral

Thanks Meagan - I didn't submit the 15734 with 50. 2 lines with RT & LT. Now that you mention it, it should have been 2 lines with modifier 59 on the 2nd line.

What's the difference then with the payment policy idicator 0 vs 1?

 

[mhstrauss]

Thanks Meagan - I didn't submit the 15734 with 50. 2 lines with RT & LT. Now that you mention it, it should have been 2 lines with modifier 59 on the 2nd line.

What's the difference then with the payment policy idicator 0 vs 1?

Indicator 0 = bilateral payment does not apply
Indicator 1 = bilateral payment DOES apply

This is in the first sentence of each description in the copy of the instructions I have downloaded.

 

[nlbarnes]

Bilateral

Good morning Meagan. I have the code descriptors and see that payment adjustment doesn't apply to 0 (150% payment adjustment does not apply and the bilateral adjustment is inappropriate) but does to 1 (payment adjustment for bilateral procedures applies). I just don't understand the difference.

I think now that I'm looking at it for the 1000th time, on the 0 indicatior, it's paid at 150% because it's viewed as a mutiple procedure and paying like a multiple procedure line item claim (not necessarily bilateral). But still, the fact that it says "payment adjustment DOES NOT apply" is really throwing me off.

I don't even want ot over think the policy indicator 1 right now. But if you have time to explain that and clarify my thoughts on ZERO, I'd appreciate it. I've been using this for years and apparantly have misinterpreted all along and convinced payers to pay 100% of fee schedule because I was so convinced, I convinced them.

Thanks so much...