Health Information Management

Q&A: Coding for bilateral procedures

JustCoding News: Outpatient, December 16, 2009

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QUESTION: Coders have two choices for how to report procedures that physicians perform bilaterally:

  • Assign one CPT® code with modifier -50
  • Assign two CPT codes without any modifier

When the technician performs the exact same radiology procedure bilaterally, does this same rule above apply?

Consider the following example: A patient had a radiologic examination, hand; minimum of three views. So the physician performed the procedure described for CPT code 73130 (Radiologic examination, hand; minimum of three views) on both the right and left hands. What is the proper way to code this procedure?

ANSWER: As you accurately stated, the number of views often determines which radiology code to use. Each view requires additional work on the part of the technician (e.g., repositioning the patient and/or camera) or additional supplies. Each view also requires additional work for the physician interpreting the images and writing the report. Therefore, this is not as much an issue of bilateral circumstances but actually reporting services performed on additional anatomical site(s).

Using your example, when the technician takes three views of the right hand and takes three views of the left hand, I recommend reporting the following if your payer accepts HCPCS Level II modifiers:

  • CPT code 73130-RT
  • CPT code 73130-LT

If not, I would suggest reporting:

  • CPT code 73130
  • CPT code 73130-59 and append documentation and explanation

To take this example to the next level, if the technician took only one view of the right hand and took two views of the left hand, you would report:

  • CPT code 73120-LT
  • CPT code 73120-52-RT

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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