Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 50: Bilateral Procedure
Policy #:MA03.002e

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The Company applies the Centers for Medicare & Medicaid Services' (CMS) Physician Fee Schedule Database bilateral indicators to procedure codes to determine 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 with 1 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 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. Payment is based on 100 percent for each procedure performed.
    • When 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, 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 with 1 in the number of services field.
  • 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.
Policy Guidelines

This policy is consistent with Current Procedural Terminology (CPT) and Centers for Medicare & Medicaid Services (CMS) reporting requirements.

When reporting a bilateral service or procedure with modifier 50:
  • Modifier LT (left side) and RT (right side) should not be reported in conjunction with a procedure or service.
  • Procedure codes identified by their terminology description as bilateral or unilateral, should not be reported.
  • Procedure codes should be reported as one service unit.
  • The appropriate procedure code and/or modifier should be used.
  • The Company applies multiple surgery reduction logic when appropriate.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, procedures or services appropriate to be reported with modifier 50 are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Bilateral procedures are procedures that can be performed on identical anatomic sites, aspects, or organs (eg, arms, legs, kidneys) during the same operative session or on the same day.

Modifier 50 (bilateral procedure) is appended to the procedure code to indicate that the procedure was performed on both sides of the body or body part during the same operative session or on the same day.

Procedure codes containing the terms bilateral or unilateral or bilateral in their descriptions cannot be reported with modifier 50 (bilateral procedure). These codes by their terminology description already identify the service as bilateral.

Modifier LT (left side) or RT (right side) is used to indicate on which side of the body a service or procedure is performed. They do not indicate a bilateral service and should not be used to report a service or procedure performed bilaterally.
References

American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. §40.8. pg. 95-97. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

Centers for Medicare & Medicare Services (CMS). PFS Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Optum360. 2018 Understanding Modifiers: Softbound.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the BILAT SURG column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to the CMS Physician Fee Schedules’ page to perform a search for Current Procedural Terminology (CPT) codes within the BILAT SURG column: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html


Select the calendar year and RVU. The RVU is separated by quarters:
RVUA (January - March)
RVUB (April-June)
RVUC (July-September)
RVUD (October - December)



Revenue Code Number(s)

N/A


Misc Code

Modifier:

50 Bilateral Procedure



Coding and Billing Requirements






Policy History

REVISIONS FROM MA03.002e
07/01/2020This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2020.

REVISIONS FROM MA03.002d
04/01/2020This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2020.

REVISIONS FROM MA03.002c
01/01/2020This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2020.

REVISIONS FROM MA03.002b:
01/01/2018Revised policy number MA03.002b was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.

REVISIONS FROM MA03.002a:
01/01/2017Revised policy number MA03.002a was issued as a result of annual policy. The References were updated accordingly. The adoptable source for this policy is CMS.

The following language was added to the Policy section:.

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

REVISIONS FROM MA03.002:
01/01/2015This is a new policy.




Version Effective Date: 07/01/2020
Version Issued Date: 07/07/2020
Version Reissued Date: N/A