Health Information Management

Q/A: Difference between bilateral coding and payment

APCs Insider, December 7, 2012

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Q: Our physicians perform a bronchoscopy and scope both lungs. Lungs are bilateral organs, so correct coding requires that we append modifier -50 (bilateral procedure) to the code to indicate that it was a bilateral procedure. However, we are not being paid for a bilateral procedure on Medicare claims. We tried to appeal but CMS said we have no grounds. Do you have any insight into this?

A: This is a “correct coding” versus reimbursement methodology situation. Correct coding does require that modifier -50 be appended to reflect a bilateral procedure. However, CMS considers a bronchoscopy to be a bilateral procedure so modifier -50 has no reimbursement impact.

 

When the claim is processed, CMS claims processing system ignores the modifier for reimbursement purposes. The Medicare Physician Fee Schedule file will assist in determining if correct payment was made. It includes a “bilateral surgery” column that indicates whether modifier -50 would be applicable.
The bronchoscopy codes have an indicator of “0” which means that this procedure cannot be expressed as bilateral and therefore modifier -50 is not applicable. While hospitals are not paid for this service under the fee schedule, the bilateral surgery indication is applicable for services reimbursed under the OPPS.
 
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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