This policy applies to professional providers billing professional or outpatient facility claims, for members enrolled in all Company products.
Modifier 50 (bilateral procedure) is used to indicate that a procedure or service was performed on both sides of the body or body part during the same session or on the same day. The Company applies the Centers for Medicare & Medicaid Services' (CMS) Physician Fee Schedule Database bilateral indicators to procedure codes to determine the eligibility for reimbursement consideration:
0 = Procedure codes with this indicator should not be reported with modifier 50. It is inappropriate to report these codes with modifier 50 because of physiology or anatomy, or because the code specifically states that it is a unilateral procedure and another code for bilateral exists.
- When reported with modifier 50, procedure codes with an indicator of 0 will be denied as an invalid procedure code/modifier combination.
1 = Procedure codes with this indicator are appropriate to be reported with modifier 50. These are unilateral services that can be performed on paired organs or body parts.
- When performed bilaterally and reported with modifier 50, procedure codes with an indicator of 1 will be considered for reimbursement at 150 percent of the provider's applicable contracted rate, which accounts for multiple surgery reductions when bilateral surgical procedures are performed.
- When bilateral surgical procedures are performed in conjunction with other surgical procedures, multiple surgery reduction logic will be applied.
- Procedure codes appended with modifier 50 should be reported as one unit in the number of services field. It is inappropriate to report bilateral services with more than one unit of service.
- The Company will deny services when modifier 50 is appended to the procedure code and more than one unit of service is reported.
2 = Procedure codes with this indicator should not be reported with modifier 50. These codes by their terminology description state that the procedure may be performed unilaterally or bilaterally.
- The bilateral payment adjustment does not apply as the allowance has been precalculated for the code.
- When reported with modifier 50, procedure codes with an indicator of 2 will be denied as an invalid procedure code/modifier combination.
3 = Procedure codes with this indicator are appropriate to be reported with modifier 50. These are typically nonsurgical services that can be performed on paired organs or body parts but are not subject to the standard payment rule for bilateral surgical procedures.
- When a procedure or service is performed bilaterally and reported with modifier 50, procedure codes with an indicator of 3 will be considered for reimbursement at 200 percent of the provider's applicable contracted rate (100 percent for each side), as these are typically nonsurgical in nature and, therefore, would not be subject to multiple surgery reductions when performed bilaterally.
- Procedure codes appended with modifier 50 should be reported as one unit in the number of services field.
- The Company will deny services when modifier 50 is appended to the procedure code and more than one unit of service is reported.
9 = Procedure codes with this indicator should not be reported with modifier 50. The concept of bilateral does not apply to these procedure codes.
- When reported with modifier 50, procedure codes with an indicator of 9 will be denied as an invalid procedure code/modifier combination.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
