Billing for bilateral procedures can be a headache. Does one use modifier 50, or go with RT and LT? The answer isn't simple. It depends on the payer. And by "depends," I mean "can drive you up the wall." Let's dig into the billing guidelines for each and see which route might save your practice time and money.
Understanding Modifier 50
Modifier 50 is billed on a single line to indicate that the procedure was performed bilaterally on both sides of the body. This modifier is typically used to convey that a single surgery or service was performed on paired body parts, like knees, eyes, or arms. Here's the kicker: it only works this way if the payer recognizes it.
Payer Preferences
Medicare is a fan of modifier 50. When billing to Medicare, it often results in a payment of 150% of the regular fee, assuming the procedure is covered as bilateral. Sounds great, right? But not all payers play nice. Some commercial insurers might process it as though you performed only one procedure, reimbursing you at 100% of the standard rate.
Using RT and LT
Alternatively, RT (right) and LT (left) modifiers are used when there's a need to indicate the specific side of the body on which the procedure was performed. Many payers expect two separate lines—one with RT and one with LT—if you're billing this way.
When to Use RT/LT
Some payers, especially those in the commercial space, insist on RT and LT for bilateral billing. This translates into separate line items for each side, which sometimes results in two payments each at 100% of the allowable rate. It's double the work in terms of data entry, but it can prevent underpayment when a payer doesn't recognize modifier 50.
How to Know Which Modifier to Use
Herein lies the challenge. Payer policies aren't always transparent, and they change. Often. You might find yourself diving into a payer's online portal, sifting through archaic documents or, worse, waiting on hold for hours with customer service. (You know the drill: elevator music on loop, interspersed with "Your call is important to us.")
Payer Guidelines and Contracts
Consult payer-specific guidelines directly. Medicare's guidelines are more standardized, but commercial insurers have individual quirks. Some might even switch recommendations mid-year just to keep billers on their toes. It's wise to periodically review the contract you have with each payer to stay updated on their preferred billing practices.
Trial and Error
Yes, the scientific method—trial and error—still applies in billing. Keep track of claims denied due to incorrect modifier use, and adjust accordingly. It’s not ideal, but practical knowledge trumps theoretical perfection.
Common Pitfalls
Inconsistent Documentation
Modifier errors can often be traced back to documentation issues. Ensure that the medical records clearly indicate the bilateral nature of the procedure. This can save questions in the case of an audit or claim dispute.
Claims Reprocessing
Be ready for claims reprocessing if the wrong modifier was applied. Modifier changes can be instrumental in overturning denials. However, remember that this might delay payment. Having a dedicated team to handle these adjustments can expedite the process.
The Cost of Modifier Mishaps
Modifier selection isn't just an academic exercise—it has real financial implications. Using the wrong modifier can lead to underpayments or denials, which directly impact the bottom line. If a single denial means $500 less in revenue and it takes three hours to resolve, what's the real cost?
A Forward-Looking Approach
Moving forward, equip your team with the latest payer updates. Invest in training sessions every quarter, encouraging your billing staff to share insights about specific payer behavior. And don't forget to use technology. Software that flags mismatches between expected and actual payments can alert you to potential errors preemptively.
At the end of the day, the goal is to ensure that your practice is reimbursed accurately for the services provided. Keeping a close eye on payer trends and being proactive in adapting to policy changes will go a long way. It's not just about getting paid—it's about getting paid what you're owed.
Related Articles
