How to Bill Bilateral Procedures in Ophthalmology: Modifier 50 Explained

Bilateral procedure billing can be a training challenge when your eyecare practice hires coders and billers from different specialties.

Pros who are used to single codes for a procedure can have a hard time getting used to unique ophthalmology abbreviations and terminology. And adding a modifier to code for which eye was treated takes a while to become second nature.

Besides remembering to use a modifier, staff need to remember which modifier to use. Mistakes can hurt the practice’s cash flow through claims denials and delays. They can trigger underpayment or overpayment, wreaking havoc on the books. Errors can even put you at risk for an audit.

This guide will cover the ins and outs of correctly coding bilateral procedures in ophthalmology, including how technology can help optimize your process. We’ll discuss when to use different bilateral procedure modifiers and offer step-by-step instructions to avoid mistakes before they cost you time and money.

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Defining ‘Bilateral Procedure’ in Ophthalmology

In ophthalmology, a procedure is bilateral if it is performed on both eyes in the same treatment session. “Bilateral” literally means “both sides,” so a “bilateral procedure” is performed on both the left and right eye.

Some CPT codes, like the code for ophthalmoscopy, are inherently bilateral. Payers assume both eyes were treated at the same time.

Other procedures might only affect one eye. For example, cataract removal could be performed on both eyes in the same treatment. Or the patient may have one eye treated and then the other treated some weeks later. Or there may only be a need to treat one eye.

The payer can’t inherently know which is the case, so it considers each eye separately. If both eyes were treated in the same visit, the CPT code needs a modifier. Otherwise, the practice risks being reimbursed for just one eye though they performed the procedure twice.

It might seem easier to just use a modifier for every “two-eyes” procedure, to be safe. Unfortunately, adding a modifier to a code that’s assumed bilateral would be a coding error.

It could lead to the claim being denied and needing rework, or to overpayment that will later have to be reimbursed.

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How to Code Bilateral Procedures in Ophthalmology in 5 Steps

Here’s your step-by-step guide to correctly coding bilateral procedures in ophthalmology:

Step 1: Confirm the Procedure Was Bilateral

The first step is to confirm whether the procedure was truly bilateral: Was the same procedure performed on both eyes in the same visit?

Step 2: Check If You Need a Modifier

Then, check whether the CPT code needs a modifier or if it is inherently bilateral.

If it needs a modifier, things get a little tricky, because now we have to decide which modifier to use.

Modifier 50

Modifier 50 is a CPT modifier that indicates a bilateral procedure. It’s common in medical specialties involving paired organs, like ophthalmology, otolaryngology, and orthopedics.

Modifier 50 is the bilateral modifier preferred by Medicare and some private payer systems, such as UHC. Reimbursement is typically 150% of the amount allowed for one side.

Modifier 50 is billed on one line as a single unit, e.g., “punctal plug insertion in both eyes, 68761-50.”

RT/LT

Modifier 50 is not the only bilateral modifier — and some payers, like BCBS, don’t recognize it.

Those payers prefer RT/LT, or right-side/left-side, modifiers. When a procedure is performed on just one eye, RT/LT tells the payer which one. If the procedure is bilateral, the payer wants to see both eyes noted individually.

Reimbursement for RT/LT procedures is usually 100% per side, for a total of 200%.

RT/LT is billed on two separate lines, with one unit per line, for example:

68761-RT
68761-LT

When to Use Modifier 50 vs. RT/LT

One quick answer to which modifier to use might be found in the date of service. Modifier 50 only applies if both eyes were treated in the same session; otherwise, use RT/LT.

Step 3: Check Units and Fees

Once you’ve applied the right modifier, double-check the units and fees. RT/LT is billed as two units, on two separate lines. Modifier 50 is usually billed as one unit, unless the payer requires it to be billed as two.

Step 4: Check for Conflicts

Review the bill for NCCI accuracy and make sure there are no conflicting bundling or procedure exclusions.

Step 5: Do a Final Sweep for Denial Triggers

Before submitting, do one last check for denial triggers like missing modifiers or inappropriate units.

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Using the Right Tools Improves Ophthalmology Coding Accuracy

Following these step-by-step instructions will help your ophthalmology billing team submit accurate bills that get paid quickly. But when you consider the time it takes to go through each step, times the number of procedures they have to code, it can feel like a daunting task.

When the department is overwhelmed, one of two things tends to happen: The bills still come out accurately, but a backlog develops, or the team tries to work fast and mistakes happen.

The right ophthalmology EHR can empower your team to keep up the pace and the accuracy, without feeling overwhelmed. Nextech’s flexible ophthalmology platform with integrated practice management software lets your team develop customized workflows so tasks get done in a way that feels intuitive. It improves communication between departments and helps you find and eliminate bottlenecks in the flow.

Coders and billers save time with built-in payer rules that eliminate the need to double-check the preferences of each payer. Pre-filled forms and modifier prompts reduce the amount of manual data entry, saving time and improving accuracy. If an error does occur, automated claim scrubbing can catch it before it costs you.

Nextech’s ophthalmology platform seamlessly combines a powerful EHR with practice management to help you run an efficient, growing business. Reporting tools that track denials and overpayments alert you when there’s a problem and help you fix it at its source.

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Frequently Asked Questions

What is Modifier 50 used for?

Modifier 50 is a CPT code modifier that indicates the same procedure was performed on both sides of the body in the same treatment session.

How do I bill a bilateral procedure that was done on different days?

If each eye was treated on a different day, bill each separately, on its own line. Use modifier RT for the right eye and LT for the left eye, and match each with the correct date of service. Do not use Modifier 50; that’s only for procedures that were performed on both eyes on the same day.

Why was my claim using Modifier 50 denied?

Common reasons for a claim denial involving Modifier 50 include:

• The procedure was inherently bilateral and doesn’t need a modifier
• The payer doesn’t accept Modifier 50
• You used a unit count of 2
• There was a conflict with other modifiers

Does Modifier 50 always mean 150% payment?

No. It depends on the payer and the contract. Medicare typically pays 150%, but private payers may pay 200%.