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Claim Payment Policy

Title:Modifier 50: Bilateral Procedure

Policy #:03.00.05g


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.


Intent
The intent of this policy is to communicate the Company's reporting requirements for modifier 50 (bilateral procedure).

For information on policies related to modifier 50, such as modifier LT/RT (left side/right side procedures), refer to the Cross References section in this policy.

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.

Policy
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.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, procedures or services appropriate to be reported with modifier 50 are covered under the medical benefits of the Company's products.

MEDICARE

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

References
Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3, Chapter XV: Fee Schedule for Physicians' Service. §15040 Bilateral Surgery. [CMS Web site]. 09/01/01. Available at: http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021921&intNumPerPage=10 (zip folder: b3_15000_to_15903.doc). Accessed May 25, 2010.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System. Pub 100-04: Medicare Claims Processing. Transmittal 1482, change request 5980. April update to the 2008 Medicare physician fee schedule database. [CMS Web site]. 03/21/08. (Effective: 01/01/08). Available at: http://www.cms.hhs.gov/transmittals/downloads/R1482CP.pdf. Accessed May 25, 2010.

Centers for Medicare & Medicaid Services (CMS). CMS Medicare Learning Network. Provider Inquiry
Assistance: Payment of Bilateral Procedures in a Method II Critical Access Hospital (CAH) – JA6526.
[CMS Web site.] 01/01/10. (Effective: 01/01/08) Available at: http://www.cms.gov/contractorlearningresources/downloads/ja6526.pdf. Accessed April 29, 2010.

Highmark Medicare Services. Medicare A/B Reference Manual. Chapter 22.1: Global Surgery and Related Issues. [Highmark Medicare Services Web site]. 05/24/10. Available at: https://www.highmarkmedicareservices.com/refman/chapter-22.html. Accessed May 25, 2010.
Coding Table

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.

Code SystemCode Number(s) and Narrative(s)
CPTRefer to Medicare's Physician Fee Schedule Search page to perform a search for Current Procedural Terminology (CPT) codes and the corresponding bilateral indicators:

http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=descending&intNumPerPage=10
ICD ProcedureN/A
ICD DiagnosisN/A
HCPCS Level IIRefer to the CMS Physician Fee Schedules’ page to perform a search for HCPCS codes and the corresponding cosurgery indicators:

http://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=descending&intNumPerPage=10
Modifier50: Bilateral Procedure
Revenue CodesN/A
      Cross References
      Version Effective Date: 01/01/2010

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      The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2012 AmeriHealth, Inc. All Rights Reserved.  Current Procedural Terminology ©2012 American Medical Association. All Rights Reserved.
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