Different reporting requirement for bilateral procedures

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Reference no: EM133925221

Question

The full contracted allowed amount for code 50200 is $237.00, and 50% of the allowed amount is $118.50. Therefore, since the first procedure should be paid at 100% of the allowed amount ($237.00), and the second bilateral procedure performed should be paid at 50% ($118.50) = the total of $355.50 is due from the third-party payers for each date of service this bilateral procedure 50200 was billed.

However, one of the payers has a different reporting requirement for bilateral procedures, requiring that 2-line items be submitted with the second CPT code appended with the modifier 50. Therefore, the claims were processed incorrectly.

One of the billing department staff noticed that this payer has only been reimbursing 50% of the contracted allowed amount on the single line item reported on the claim ($118.50) and adjusted the rest of the balance. The billing staff entering the payer payments adjusted off the rest of the balances for these claims. This is a monetary loss of $237.00 for each patient. With 80 patients - that is a loss of $18,960 that the physician is due.

Reference no: EM133925221

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