Generally, you may bill bilateral procedures in the following ways:
- Bill the same code as two line items, using the same code on each line. ...
- Bill the bilateral procedures as two line items, using the same code on each line. ...
- Bill the procedure as a single line item on the claim form with a modifier -50 on the procedure code. ...
- Bill the same code as two line items with no modifiers. ...
How to Bill bilateral procedures?
Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure).
Can ASC bill for DME?
SNF billing Guide If the ASC furnishes items of implantable DME to patients, the ASC bills and receives a single payment from the local contractor for the covered surgical procedure and the implantable device, as long as the implantable device does not have pass-through status under OPPS.
How does Medicare affect medical billing?
Obamacare’s Affect on Medical Billing and Coding
- Increased Demand for Work. One of the undeniable facts about Obamacare is that more Americans will have health insurance, which means that demand for coding and billing professionals is bound ...
- Cumbersome Government-Related Processing Issues. ...
- Increased Medicare Efficiency. ...
- Job Outlook. ...
What are the requirements for Medicare billing?
- The regular physician is unavailable to provide the service.
- The beneficiary has arranged or seeks to receive the services from the regular physician.
- The locum tenens is NOT an employee of the regular physician.
- The regular physician pays the locum tenens physician on a per diem or fee-for-service basis.
How do you bill bilateral?
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
What modifier do you use for bilateral?
The MPFS Relative Value File shows a 1 modifier indicator in the BILAT SURG column for this code; therefore, modifier 50 may be appended to describe a bilateral procedure (for example, for excision of a lesion on the left arm, and another excision of lesion of the same type on the right arm).
How do you bill bilateral injections?
Question: What is the appropriate way to bill a bilateral injection and drug?67028 -50, 1 unit and double the amount. Submit with the bilateral diagnosis.For the drug, double the units and bill the bilateral diagnosis.
What is the typical reimbursement rate for bilateral procedures?
150%Bilateral procedure fee adjustments are applied to procedure codes with a bilateral procedure indicator of “1” on the MPFSDB. These procedures will be reimbursed at 150% of the usual applicable fee schedule rate.
Does Medicare accept modifier LT and RT?
If the service is submitted using a modifier 50 or the RT/LT or two units of service, then Medicare will allow the fee schedule for both services. Apply the multiple surgery rules prior to applying the multiple payment reduction rules.
Can RT and LT modifier be used together?
Do not use the combination RTLT modifier on the same claim line and bill with 2 units of service (UOS). Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single claim line, will be rejected as incorrect coding.
How do I bill bilateral knee injections to Medicare?
Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT 20610). Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.
How do I bill Medicare for joint injections?
Billing the injection procedure The procedure code (CPT code) 20610 may be billed for the intraarticular injection. The charge, if any, for the drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.
How do I bill for multiple joint injections?
Report a single unit of 20600-20611 for each joint treated, regardless of how many aspirations and/or injections occur in a single joint. You may report multiple units of a single code for aspiration/injection of multiple joints of same size (e.g., two large joints, left knee and left shoulder).
How do I bill 69210 Bilateral to Medicare?
A: The coder would report CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) with modifier -50 (bilateral procedure) twice. Alternatively, the coder could report code 69210 twice with modifiers -LT (left side) and -RT (right side).
What is a 52 modifier used for?
Modifier 52 This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service.
How do I know if a CPT code is bilateral?
If the code has an indicator of two, it is a bilateral procedure code. You would not need to add a modifier 50 because the code is already bilateral. A code with this indicator lets the insurance company know that both sides were done. Claims will be processed at 100% of the allowable.
Identifying Bilateral Codes
In some cases, descriptors for procedure codes can be included within the description itself.
MPFS Indicator "B" - Descriptors
CPT 27331 has a bilateral indicator of a 1, which means bilateral surgery rules apply. If the 50 modifier is appended to the CPT with 1 unit billed, Medicare will allow 150%. If billed with 2 units, it states the procedure was completed 4 times and will be denied as unprocessable.
Billing Guidelines
A procedure that is not identified by its descriptor as a bilateral procedure (or unilateral or bilateral), indicates the physician must report the procedure with the 50 modifier. For Medicare billing purposes, such procedures should be reported as a single line item.
Processing Guidelines
We (Noridian) will process claims for bilateral surgeries according to the presence of the 50 modifier on the CMS-1500 claim form, or its electronic submission, or of the same code on separate lines, one line with LT modifier and the other with the RT modifier.
Resources
Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.7
Why is coding for bilateral procedures so challenging?
Furthermore, coding for bilateral procedures is particularly challenging because it is defined in various ways.
Why is bilateral adjustment inappropriate?
The bilateral adjustment is inappropriate for codes with this indicator because of physiology or anatomy or because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1-indicator: 150 percent payment adjustment for bilateral procedures applies.
What is the unit code for Medicare?
Reporting codes that can be performed bilaterally and are not otherwise identified. Medicare and payors that follow Medicare rules, including United Healthcare, Aetna, Humana, and Cigna, require that the code be billed on one line, the unit be listed as 1, and modifier 50 be appended: Example: XXXXX–50, Units = 1.
What is a BCBS?
For example, the Blue Cross Blue Shield (BCBS) Association is composed of multiple companies, and many of them have different local coding and coverage guidelines for bilateral procedures. For a list of local BCBS Association companies, go to www.bcbs.com/about-the-companies/; bilateral procedure rules will be listed under “Provider” ...
When to use modifier LT?
In those instances, the modifier LT or RT is used to indicate the side of the body on which a service or procedure is performed.
Do providers have to wait for denials?
Providers should not wait for denials to identify a payor’s bilateral procedures claim form policy. It is important to verify a payor’s reporting preference to avoid payment denials because some payors may require one- or two-line entry or the use of HCPCS Level II RT and LT modifiers.
Can third party payers report bilateral procedures?
Third-party payors have different policies for reporting bilateral procedures on the claim form. It may be difficult to know how payors expect bilateral procedures to be represented on the claim form. Providers should not wait for denials to identify a payor’s bilateral procedures claim form policy.
Why is bilateral adjustment inappropriate?
The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1.
Is RVU bilateral or bilateral?
The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure. 3.
What is the Physician Fee Schedule Payment Policy Indicator file layout?
The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used to identify endoscopic base codes, payment policy indicators, global surgery indicators or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.
What is Medicare Administrative Contractor?
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
