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Modifier 50 - Bilateral Procedure Usage and Reimbursement


Bilateral services are procedures performed on both sides of the body during the same operative session or on the same day. The modifier "50" is not applicable to procedures that are bilateral by definition or their descriptions include the terminology as "bilateral" or "unilateral".

For example: CPT 69210 Removal impacted cerumen one or both ears. The RVUs are based on the bilateral procedure because the code descriptor specifically states that the procedure may be performed unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure.

As defined in the CPT, Modifier 50 “Bilateral Procedure: Unless otherwise identified in the listing bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five digit code.”

Modifier "50" should follow the procedure code in Item 24d of the CMS-1500 claim form, or in the equivalent electronic field, when services are rendered bilaterally (unless the code does not require this modifier as described above).

Modifier 50, is used to report diagnostic, radiology and surgical procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

Do not use Modifiers RT and LT when modifier 50 applies. A bilateral procedure is reported on one line using modifier 50 and the unit should be always one.

Reimbursement 

Reimbursement for bilateral services is determined using the Medicare Physician Fee Schedule Database (MPFSDB). The MPFSDB defines procedures that may be submitted as “bilateral” and how reimbursement is calculated.

The “Bilateral Surgery Indicator” in the MPFSDB indicates how the bilateral service must be submitted to Medicare.

To access this database, refer to the CMS Web site at: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx

The concept of a “bilateral service” applies when a procedure is performed on both sides of the body during the same operative session or on the same day.

Bilateral Surgery Indicator '0'

150% payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or with RT and LT, the payment is based on the two sides on the lower of the total charges for both sides or 100% of the fee schedule for a single code. Example: CPT code 11056 - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); two to four lesions

Submit the surgery with a quantity of 1

Do not submit these procedures with CPT modifier 50.

Bilateral Surgery Indicator '1'

150% payment adjustment for bilateral procedure applies. If the code is billed with the bilateral modifier (50), the payment is based on the lower of the total charges for both sides or 150% of the fee schedule for a single code. Example: CPT code 29805 - Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)

Submit the procedure on a single detail line with CPT modifier 50 and a quantity of “1.”

Bilateral Surgery Indicator '2'

150% payment adjustment does not apply.Relative value units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with a modifier 50 or twice on the same day by any other means, the payment is based on both sides of the total actual charge by the physician for both sides or 100% of the fee schedule for a single code. The RVUs are based on the bilateral procedure because the code descriptor specifically states that the procedure is bilateral, the code descriptor states the procedure may be performed unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure. Example: CPT code 32853 - Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass

Submit the procedure with a quantity of “1.”

Do not submit these procedures with CPT modifier 50.

Bilateral Surgery Indicator '3'

The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day, payment is based on each side or organ or site of a paired organ on the lower actual charge for each side of 100% of the fee schedule amount for each side. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries. Example: CPT code 73040 - Radiologic examination, shoulder, arthrography, radiological supervision and interpretation

Submit the procedure on a single detail line with CPT modifier 50 and a quantity of “2.”

Bilateral Surgery Indicator '9'

Bilateral concept does not apply.

Do not submit these procedures with CPT modifier 50.

Please note: Unless specified by the carrier, do not reduce the billed amount for the second procedure, let the claims adjudication process reduce the procedure. There is a greater chance that the adjudicator applies a reduction to the procedure beyond the amount already applied than of the carrier overpaying for the second procedure.

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