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In a
perfect world, you'd be able to bill every payor the same
way, with the same rules. Unfortunately, private payors
often choose their own route, which makes your life more
complicated.
When
you bill Medicare for a bilateral procedure using the 50
modifier, the rules are pretty simple: You bill the code
once, with the 50 modifier attached. Then the Medicare carriers
automatically increase your reimbursement to 150 percent
of the code's usual RVUs.
But
many private payors and state Medicaid programs have wildly
different rules. Some of them want you to bill the code
twice, on two lines, with the 50 modifier attached to the
second line. Others require you to bill two units of the
code on one line, and attach the 50 modifier.
Blue
Cross/Blue Shield of South Carolina recently wrote to providers
to say that it would no longer recognize the 50 modifier
with a single unit on a single line, according to Hidy Borden,
senior reimbursement analyst with the Medical University
of South Carolina in Charleston. Instead, providers must
either use two lines, or two units on a single line.
To add
to the confusion, the change applied to some of the Blue
Cross health plans, but not others. And the Blues rep claimed
the change also applied to South Carolina Medicare, which
Blue Cross oversees as Palmetto GBA. But so far no sign
of the change has appeared on Palmetto's Web site, and this
would be a dramatic departure from other Part B Medicare
carriers' practices.
The
reason for the change? The Blue Cross plan no longer recognizes
the 50 modifier as a "pricing modifier." In other
words, the 50 modifier would no longer automatically trigger
a change in reimbursement by itself, unless there were multiple
units.
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