MA PPO

Modifier 50: Bilateral Procedure
MA03.002e


Policy

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.

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

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 SURGcolumn: 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)


ICD - 10 Procedure Code Number(s)
N/A

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

Modifiers

50 Bilateral Procedure

Coding and Billing Requirements



Policy History

7/1/2020
7/7/2020
MA03.002
Claim Payment Policy Bulletin
Medicare Advantage
Yes