Modifier 50 appends with the services when the physician performs a “bilateral procedure.”
Modifier 50 Description
Modifier 50 applies to the procedure when the physician performs bilateral services such as both upper and lower extremities, eyes, etc.
Modifier 50 applies to surgical procedures or services ranging from CPT codes 10040-69990 and the radiology CPT code section when performed bilaterally. The following service performs on either side by the same physician during the same visit may represent 50.
It is appropriate to report with modifier 50 when completed in the same encounter or operative session—the claim with 50 Modifier bill as a single line on the claim form.
If the word “Bilateral” is in the CPT code descriptor for the procedure or service, adding a modifier 50 with these CPT codes is inappropriate such as CPT code 27395 (The Physician performs the lengthening of hamstring tendon bilaterally on multiple sites).
The physician performs the cystourethroscopy with meatotomy, either unilateral or bilateral. It may only report 1 unit for the service when any operation or procedure performs on both sides, such as FL 46. If the word “Unilateral or Bilateral” is in the CPT code descriptor for the procedure or service, adding a 50 with these CPT codes is inappropriate such as CPT code 52290.
Suppose the procedure or service does not contain bilateral or unilateral in the code descriptor and perform during the same session and encounter. In that case, it reports by adding 50 for reimbursement with five-digit CPT codes. Modifier 50 is inappropriate to append with the “add on” code that lists in appendix F in AMA CPT professional book.
Some commercial insurance or payor may require modifier RT and LT instead of a modifier when reporting for the bilateral procedures. For instance, The physician performs a knee X-ray on both right and left sides. Therefore, it may bill as two lines, such as 73562-RT and 73562-LT, instead of one line with modifier 50, 73562-50.
Modifier LT and RT inappropriate report on the same line with 50 represents the bilateral procedures. It may have a choice of either bill as two lines or as a single line with 50 if appropriate according to a third party or payor guidelines.
What Is Modifier 50?
Modifier 50 is appropriate for the services when the physician performs the procedures on both sides or bilaterally, such as on both hands, arms, foot, eyes, etc.
When To Use Modifier 50
The following are the uses of 50 when applicable:
Modifier 50 uses when the physician performs the bilateral procedure during one session, and the Medicare-Physician-Fee-schedule-Relative-Value File (MPFSRVF), also known as the Medicare Physician Fee Schedule Database (MPFSDB) BILAT SURG indicator is 1 or 3.
Modifier 50 is appropriate to append with bilateral procedure surgery indicator one as 1 unit of service on the claim line.
50 Modifier is appropriate to append with bilateral procedure surgery indicator of 3 as 1 unit of service on claim line when performed on bilateral body parts.
50 is appropriate to append with the bilateral procedure during the same session by the same physician in either same (e.g., nose, eyes, breasts) or different operative areas (e.g., hands, feet, legs, arms, ears).
Modifier 50 Guidelines
Modifier 50 is inappropriate to report when the physician performs the procedure on a different anatomical location on the same body side.
Modifier 50 is inappropriate to report with bilateral surgery indicators 0, 2, and 9.
50 is inapplicable to attach when the physician removes lesions on the right and left arm. Therefore, it is appropriate to report with modifiers RT and LT.
50 Modifier is inappropriate to report with the service when the CPT code descriptors include unilateral or Bilateral.
50 is inappropriate to report with the service as two lines are on the second line of the service claim.
Modifier 50 is inapplicable to report with midline organs such as the uterus, esophagus, bladder, and nasal septum.
Bilateral Indicator 0 is not applicable with 50 because physiology does not consider bilateral body parts, and The code descriptor contains “bilateral procedure.” It may also not include a procedure billed with modifier RT and LT instead of 50, service does not meet bilateral standards, and the 150 percent payment adjustment rule may not apply.
Bilateral Indicator 1 is appropriate to report with 50 unless the code descriptor includes the bilateral procedure. The claim may process as one line, such as 76641-50.
It may lead to incorrect processing of claims without 50. If the procedure performs unilaterally, using either LT or RT modifier as 1 unit is appropriate. The 150 percent payment adjustment applies to indicator 1.
Bilateral Indicator 2 indicators mean that these CPT codes establish a bilateral procedure. It does not apply to bilateral procedure codes.
Bilateral Indicator 3 means that the physician performs the bilateral procedure with LT or RT modifier. In contrast, Indicator 9 indicates the services cannot bill with modifier 50 and LT or RT.
Modifier 50 Examples
The following are examples of when modifier 50 appends with CPT codes:
A 39-year-old male with tumors on the lumbar region presented to the emergency department with c/o constant low back pain that started four days ago. The patient was unable to walk for 1-week.
The patient is consulted with his primary care physician and suggested to go emergency department. Denies trauma, heavy palpitations, dizziness, cough, recent illness, fever, chills, back pain, abdominal pain, nausea, recent travel, known sick contacts, current antibiotic use, near-syncope or syncope, changes in stool color, urinary complaints, or any other symptoms.
The patient took his routine medication. Next, the physician ordered a CT scan of the lumbar region and laboratory studies to confirm if the tumor metastasized or not. Finally, the physician decides to do a surgical procedure to excise cancer.
The patient is back on the second day of surgery with severe pain and decided to administer an anesthetic agent at bilateral L4-45 in the epidural space. The process performs successfully.
A 32 year-0ld female presents to the office with pain in her right and left hand. She accidentally triggered his finger four days ago. She took medication for pain relief, but it still did not resolve.
The patient denies headache, shortness of breath, back pain, abdominal pain, nausea, vomiting, diarrhea, changes in vision, urinary complaints, or other symptoms.
The physician ordered a trigger injection for pain.
Office and Lab Procedures: Trigger Finger Injection
Location: injection of tendon sheath Right and left hand
Injectate: Lidocaine 1 mL; Celestone;
Fluoroscopy time less than 0.1 minutes.
Procedure: The physician discussed the risks, benefits, and alternatives, including infection, tendon rupture, skin depigmentation, and fat atrophy. The patient consented to proceed with a cortisone injection into the right and left-hand flexor sheath. The patient tolerated the procedure well.
A sixteen-year-old male presented to the emergency department after a motor vehicle accident today and had a severe headache, back pain, and shoulder. In addition, the patient is unable to move and has severe knee pain.
The patient denies urinary symptoms, extremity pain, and dizziness, and the physical exam revealed neck and eye swelling. The physician ordered a CT and ultrasound of the shoulder, head, and Lumbar. It revealed traumatic injury of the knee.
The physician consulted with orthopedics and suggested total shoulder arthroplasty on bilateral sides. The physician scheduled the total shoulder arthroplasty bilateral for next week, and he was prescribed medications for further treatment.
Modifier 50 Reimbursement
if Modifier 50 appends with the service or procedure appropriately, It may enhance the refund to 150 % according to the allowable amount of physician fee schedules for commercial and Medicare insurance.
For Instance, The physician sees the medicare patient and excises the malignant lesion of the trunk region, up to 0.5 cm or less. The MPFS Relative Value shows the bilateral indicator one and is appropriate to bill with 50. CPT code 11600 may report with service, and the allowable is $200. The amount may increase to $300 when reported with modifier 50.
Some commercial insurance may require modifier RT and LT instead of 50. For example, medicare part B claims should always bill with modifier 50. However, the other insurance may ask you to bill as two-line, such as 11600, 11600-50. Modifier 50 appends with the second line on the claim.
CPT Code 20610 Modifier 50
Modifier 50 is appropriate to bill with the CPT code 20610 when the physician performs the bilateral procedure. However, it is inappropriate to bill with 50 when executed on both sides but in distinct anatomical locations.
If the physician performs two injections on the patient’s right and left shoulder, it is appropriate to report CPT code 20610 with modifier 50.
If the physician performs two injections on the patient’s right shoulder and left knee, it is appropriate to report CPT code 20610 with RT modifier and for knee 20610-59-LT. Modifier 59 indicates the distinct location, and it may not require if performed on the exact anatomical location.
69210 Modifier 50
CPT code 69210 contains unilateral in code descriptor, but it is appropriate to report with modifier 50 according to AMA CPT Book guidelines. Commercial payers may have different policies and ask you to bill as two lines with modifier LT and RT if performed on the exact location on bilateral sides.
Procedure Code For Modifier 50
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 50 as described above).
Use Of Other Modifiers
Do not use Modifier RT and and Modifier LT when Modifier 50 applies. A bilateral procedure is reported on one line using 50 description and the unit should be always one.
Bilateral Surgery Indicator ‘0’
150% payment adjustment for bilateral procedures does not apply. If the procedure is reported with 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, 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 description 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 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 description and a quantity of “2.”
Bilateral Surgery Indicator ‘9’
Bilateral concept does not apply.
Do not submit these procedures with CPT modifier 50.