Effective for claims received on and after August 16, 2019, services will be rejected as unprocessable when the procedure code reported is inconsistent with the modifier used. The modifier 50 is defined as a bilateral procedure performed on both sides of the body. Appropriate use
Full Answer
What does modifier 50 mean in a radiology code?
"1" indicates modifier 50 can be appropriate. "2" indicates a bilateral code; modifier 50 is not billable. "3" indicates primary radiology codes; modifier 50 is not billable. "9" indicates that the concept does not apply. (office visit)
What is modifier FY for X-rays?
To implement this provision, the Centers for Medicare & Medicaid Services (CMS) created modifier FY (Computed radiography services furnished). Beginning in 2018, claims for computed radiography services that are furnished for X-rays must include modifier FY that will result in the applicable payment reduction.
What is inappropriate usage of modifier 50 for breast augmentation?
Inappropriate usage includes: 1 Do not use modifier 50 when performing the procedure on different areas of the same side of the body. 2 Do not use modifier 50 when the BILAT SURG indicator is 0, 2 or 9. 3 Do not use modifier 50 when removing a lesion on the right arm and a lesion on the left arm. ... More items...
What is the difference between modifier 50 and Procedure Code 19303?
Note: It is recommended that an anatomical modifier be included in addition to modifier 50 to show the additional services are not duplicates. Procedure code 19303 (Mastectomy, simple, complete) is performed bilaterally
Does Medicare accept the 50 modifier?
Medicare will allow 100% of the highest paying surgical procedure on the claim plus 50% for the other ASC-covered surgical procedures furnished in the same session.
Is 50 modifier still valid?
As of January 1, 2020, you will no longer be able to report modifier 50 with add-on codes. Add-on codes describe services that are always performed in conjunction with a primary service by the same provider in the same encounter or patient session.
Why is modifier 51 exempt from being used in the medicine section?
Modifier 51 comes into play only when two or more procedures are performed. It is not to be used when a procedure is performed along with an Evaluation and Management (E/M) service. There are instances where multiple procedures are performed but modifier 51 is not appropriate.
What CPT codes are not accepted by Medicare?
Certain services are never considered for payment by Medicare. These include preventive examinations represented by CPT codes 99381-99397. Medicare only covers three immunizations (influenza, pneumonia, and hepatitis B) as prophylactic physician services.
Can you use modifier 50 on xray?
As indicated in §20.6. 2, modifier -50, while it may be used with diagnostic and radiology procedures as well as with surgical procedures, should be used to report bilateral procedures that are performed at the same operative session as a single line item.
When should modifier 50 be used?
bilateral proceduresUse 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 is the difference between modifier 50 and 51?
Modifier 50 Bilateral procedure describes procedures or services that take place on identical, opposing structures (e.g., shoulder joints, breasts, eyes). Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services) during the same session.
Does Medicare recognize modifier 51?
Medicare does not recommend reporting Modifier 51 on your claim; the processing system has hard-coded logic to append the modifier to the correct procedure code.
When should modifier 51 not be used?
Modifier 51 comes into play only when two or more procedures are performed. It is not to be used when a procedure is performed along with an Evaluation and Management (E/M) service. There are instances where multiple procedures are performed but modifier 51 is not appropriate.
What are common reasons Medicare may deny a procedure?
What are some common reasons Medicare may deny a procedure or service? 1) Medicare does not pay for the procedure / service for the patient's condition. 2) Medicare does not pay for the procedure / service as frequently as proposed. 3) Medicare does not pay for experimental procedures / services.
What modifiers are not accepted by Medicare?
Medicare will automatically reject claims that have the –GX modifier applied to any covered charges. Modifier –GX can be combined with modifiers –GY and –TS (follow up service) but will be rejected if submitted with the following modifiers: EY, GA, GL, GZ, KB, QL, TQ.
What procedures are not covered by Medicare?
Some of the items and services Medicare doesn't cover include:Long-Term Care. ... Most dental care.Eye exams related to prescribing glasses.Dentures.Cosmetic surgery.Acupuncture.Hearing aids and exams for fitting them.Routine foot care.
When will modifier 50 be unprocessable?
Modifier 50 fact sheet. Effective for claims received on and after August 16, 2019 , services will be rejected as unprocessable when the procedure code reported is inconsistent with the modifier used. The modifier 50 is defined as a bilateral procedure performed on both sides of the body.
What is inappropriate use?
Inappropriate use. Inappropriate to apply to a "bilateral description" code. Do not append to procedures for midline organs such as the bladder, uterus, esophagus, or nasal septum. Inappropriate to report when performed on different areas of same side of body.
Can you have more than one surgery in the same operative session?
When more than one surgical procedure is performed in the same operative session, multiple surgery rules apply. Medicare will allow 100% of the highest paying surgical procedure on the claim plus 50% for the other ASC-covered surgical procedures furnished in the same session. Bilateral procedures should be reported:
What is Medicare approved amount?
Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B.
What does Medicare Part B cover?
X-rays. Medicare Part B (Medical Insurance) Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. covers. medically necessary. Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
Why is bilateral indicator inappropriate?
The bilateral indicator is inappropriate for reasons such as: Physiology; is not a bilateral body part. The codes description states it is an existing bilateral procedure. The procedure is not commonly performed as bilateral. (These services do not meet the bilateral criteria.)
Does bilateral surgery concept apply to codes with status indicator 9?
Concept does not apply. Bilateral surgery concept does not apply to codes with status indicator 9. These procedure codes should not be billed with modifiers 50, LT or RT (e.g., xxxxx, billed with 1 unit).
Can you use modifier 50 with a bilateral procedure code?
Do not use modifier 50 with a procedure code that is described as bilateral, or unilateral or bilateral, in its CPT description. Do not report a bilateral procedure on two lines of service by appending modifier 50 to the second line of service.
Instructions
When performing a procedure on bilateral body parts, append payment modifier 50 to the appropriate code performed at the same session. The bilateral adjustment is inappropriate for (a) physiology or anatomy codes or (b) code descriptor that specifically states it is a unilateral procedure and there is an existing bilateral procedure code.
Resources
CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6
When to use -50 modifier?
For Bilateral procedures , use the -50 or -RT/-LT modifiers when an identical procedure is performed on both the Right and Left sides of the body. The policies payors have for the use of modifiers for reporting bilateral procedures can vary. Check with each payor for their preferred method of billing bilateral procedures.
What is a modifier in CPT?
Modifiers are two-digit symbols added to CPT procedure codes to signify the procedure has been altered in some way. Modifiers are accepted by Medicare and most other payers, however, using modifiers correctly can be confusing, since not all payers want modifiers used the same way.
Why are certain modifiers used?
Certain Modifiers are for use because the patient had to return to the OR for another procedure the same day or close to the time another procedure was performed in your facility – which is referred to as the “Global Period” or “Postoperative Period.”.
Can you use a -50 modifier on Medicare?
Billing with one line item can only be done using the -50 Modifier (which is not accepted by Medicare). Do not mix the -50 Modifier with –RT or –LT Modifiers. Do not use Bilateral Modifiers on those CPT codes with verbiage describing procedures as “Bilateral” or “Unilateral or Bilateral”. Since Medicare no longer allows the use ...
Image Gallery
When President Obama signed into law the Consolidated Appropriations Act of 2016, he did more than approve spending for a number of government agencies for the fiscal year of 2016.
Transitioning to DR
At East Texas Medical Center, Director of Radiology Bill Tobin is overseeing the transition from CR to DR. A Fujifilm CR customer since 2007, he had to make the decision whether to replace the systems with “old” technology or convert to DR.
A shift in planning
Even the best laid plans can change. When Derek Taylor, Director of Radiology at Memorial Hospital of South Bend (South Bend, IN) began planning for the conversion of film-based X-ray to DR at several health system owned outpatient centers in 2015, he and his team anticipated making the switch in 2017.
DR technology trends
With many sites—large and small—moving to DR from CR, an important consideration is the access to and management of digital images. While most hospitals will have a PACS installed, many outpatient center or group practices may not.
About the Author
Mary Beth Massat is a freelance healthcare writer based in Crystal Lake, Il.
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