New CPT coding for facet/MBB/RFA-- decreased reimbursement?

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tmvguy03

tmvguy03

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Hey all- I understand the new CPT guidelines on bilateral facets (50 mod 1st level, bill 2 units each additional). On the surface it looked like reimbursement would increase, given that typically the 50 mod reimburses 50% for the opposite side at each level. However, I was told by my billing dept that 2 units of level 2 or 3 mbb (i.e. 64491/64492 or 64494/64495) would only pay 1 unit. Therefore the opposite side at the additional levels just isn't getting paid anymore. I reviewed the billing on a couple cases that went out last month: Billed 64490 (50mod), 64491 (x2 units) And I was paid for the 64490 mod 50 and 1 unit of 64491...
Am I missing a modifier with my billing?
 
My billers told me to keep using the 50 modifier because Medicare doesn’t seem to have implemented the changes yet, and the maximum units for the add on codes is still set at 1.
 
I thought we were supposed to add the right and left modifiers for the additional levels. Could that be the issue?


Sent from my iPhone using SDN
 
That’s true- I am adding the Lt/art modifiers, but Medicare still only pays for one unit. It’s basically a 25% drop in reimbursement for facets, kind of a drag.
 
DOctorJay said:
I thought we were supposed to add the right and left modifiers for the additional levels. Could that be the issue?


Sent from my iPhone using SDN
Click to expand...

We take the extra time to be particular, add the levels, modifiers, side, and they say- “that’s nice to know. Here’s your reimbursement for one side, have a great day.“
 
that is a huge hit if its true. if thats the case, i may need to seriously into only doing 1 side at a time. that is 6 separate injection visits to ablate both sides at L3, 4, and 5. completely sucks
 
SSdoc33 said:
that is a huge hit if its true. if thats the case, i may need to seriously into only doing 1 side at a time. that is 6 separate injection visits to ablate both sides at L3, 4, and 5. completely sucks
Click to expand...

In my area Medicare will only allow you 5 “visits” per spine segment per year for facet procedures. In other words, you can’t split it up into MBBx2 on each side and 2 RFAs as it would be 6 procedures. What a mess. FWIW a quantity of 2 has been getting kicked back some for us and we are resubmitting subsequent levels with lt or rt modifiers and its going through. Sounds like this is hit or miss across the country though.
 
Seriously.... my hospital doesn't recognize the -50 modifier. I was expecting this to be a game changer for us. I guess I'm just back at square one, doing one side for free
 
bobbarker is right. you will probably get the same RVUs, but the hospital won't get paid as much. unless you have a biller that is right on top of things, it'll probably slip through the cracks.
 
dhcofc said:
In my area Medicare will only allow you 5 “visits” per spine segment per year for facet procedures. In other words, you can’t split it up into MBBx2 on each side and 2 RFAs as it would be 6 procedures. What a mess. FWIW a quantity of 2 has been getting kicked back some for us and we are resubmitting subsequent levels with lt or rt modifiers and its going through. Sounds like this is hit or miss across the country though.
Click to expand...
And that's assuming only one RFA per year. If they get 6 months relief, to bad for the rest of the year.
 
I had my biller look at this. Noridian pays a few cents less for the first level and a few cents more for the additional levels. For three level facets the payment is about $1.20 more than 2019. These are office numbers though. I don’t do any facets in the ASC to see if anything changed there.
 
Anybody with an update on this issue? My coder just figured this out and it appears the second facet joint, second level is not getting paid. Anyone going through appeal process? Anyone doing less facet joints because of it? Not a big fan of doing procedures for free..
 
spondy14 said:
Anybody with an update on this issue? My coder just figured this out and it appears the second facet joint, second level is not getting paid. Anyone going through appeal process? Anyone doing less facet joints because of it? Not a big fan of doing procedures for free..
Click to expand...
You need a new coder..she is wrong and losing you a sh'tload of money
 
spondy14 said:
Anybody with an update on this issue? My coder just figured this out and it appears the second facet joint, second level is not getting paid. Anyone going through appeal process? Anyone doing less facet joints because of it? Not a big fan of doing procedures for free..
Click to expand...

Your coder is wrong.
 
After a year of this, what is the consensus among the PP pain docs ?(not employed by a hospital on an RVU system)

Are we supposed to use a 50 modifier or X 2 for the second and third MBB levels?

And more importantly, which of these is being paid and which is not?

And is using a right left modifier necessary for the second or third levels? I'd really like to just do this in the simplest way that will still get me paid
 
Yes any input on this appreciated from pp docs..

Been doing the x2 thing. Will have to reach out to my billing department about payment but if anyone on here has some info, would appreciate
 
bedrock said:
After a year of this, what is the consensus among the PP pain docs ?(not employed by a hospital on an RVU system)

Are we supposed to use a 50 modifier or X 2 for the second and third MBB levels?

And more importantly, which of these is being paid and which is not?

And is using a right left modifier necessary for the second or third levels? I'd really like to just do this in the simplest way that will still get me paid
Click to expand...

I work for a big group. I specifically reached out about this the other month. According to my biller (who could be wrong), different insurances accept different codes. If I do a bilateral L3-5 MBB, I bill a left and right first level and second level. The billing department then goes through and selects either 50 modifier or 2 units depending on which insurance is being billed.
 
Sorry, I completely wrote my initial post wrong. For L3-5 MBB bilateral that is what I bill. For the second level people are billing 64494 mod 50 and not 64494x2 right?
 
I had our biller do an audit of 3 patients that I did bilateral L2-5 mbb's. Each produced a different total wRVU despite me doing the same procedure on all three patients! I wrote the biller about the discrepencies and have yet to hear back, 4 weeks later. Ugghhhhh
 
Do you need to wait a period of time between repeat diagnostic blocks, as well as before proceeding to RF (say 7-10 days) to avoid non-reimbursement?
 
based in WA state here, but just talked to my billing team and they tell me that even though medicare came out with that update last year saying we would need to bill the first facet level as -50 and the 2nd as 2x units. I have been trying to bill this way and it comes back for all private and even medicare so we went back to billing each facet level as -50.
 
I am starting to get some rejections from private payers for modifier 50's being an invalid modifier with CPT codes 64491 and 64492. Maybe someone can decipher what this rejection for using modifier 50 with CPT codes 64491 and 64492 means:

"Per CCI guidelines, report 64491 and 64492 in addition to 64490. If 64490 is performed bilaterally, service should be reported twice with modifier 50 appended to the second code while others require identification of the service only once with modifier 50 appended. Codes 64491 and 64492 should be reported twice when performed bilaterally. Do not report 64491 or 64492 with modifier 50."

It is a bit confusing, but I am assuming it is saying the correct way to bill a bilateral 3-level facet joint injections is to bill 64490 on line 1, 64490 modifier 50 on line 2, 64491 x2 units on line 3, and 64492 x2 units on line 4, am I correct? You do not have to specify laterality for the second and third levels when billing each of those levels with 2 units, right?
 
Stuck between a rock and a hard place. I see some doing 3 levels bilaterally. That is 8 separate ablations if they work which seems like overkill. Does anyone else limit it to 2 levels and only add on if there is not adequate coverage. Not to mention I prefer staying unilateral with RFA when possible.
 
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