Monday, May 24, 2010

Modifier 50 - Bilateral Procedure Modifier - General review

Part - A  Level I Modifiers 50 - Bilateral Procedure


Description Bilateral Procedure. This modifier is used to report bilateral procedures that are performed during the same session.

Required for Claims Hospital Outpatient Prospective Payment System (OPPS)

Type of Bill: 12x, 13X

Coding Guidelines Generally applied to surgical (CPT 10000-69990), radiological procedures (CPT 70010-79999) and other diagnostic services (CPT 90281-99569)

*Commonly seen with procedures that allow 150% of MPFS


Instructions

When performing a procedure on bilateral body parts, append payment modifier 50 to the appropriate code performed at the same session. The bilateral adjustment is inappropriate for (a) physiology or anatomy codes or (b) code descriptor that specifically states it is a unilateral procedure and there is an existing bilateral procedure code.

Correct Use

    One line appending modifier 50 or RT and LT using one unit of service
    See Bilateral Surgery Rules within Medicare Physician Fee Schedule (MPFS) Indicator Descriptions

Incorrect Use

    Inappropriate to apply an already "bilateral description" code
    Do not append to procedures for midline organs such as the bladder, uterus, esophagus or nasal septum
    Inappropriate to report when performed on different areas of same side of body


Billing Bilateral Procedures


In accordance with Current Procedural Terminology (CPT) guidelines, bilateral procedures should be billed on one line only, utilizing the modifier 50; enter one as 01 in the units field and bill your total bilateral charge.

Bilateral Billing Examples with unit

• Bilateral breast reconstruction – report as code 19357 with modifier 50 on one claim line with 01 in the units field.

• Bilateral lower and upper blepharoplasties – report as:

 - 15820 with modifier 50 on the first claim line with 01 units
 - 15822 with modifier 50 on the second claim line with 01 units

Note: For bilateral services, do not bill modifier LT/RT or any other site-specific modifier other than 50.


General Guidelines

A. Modifier –50 applies to any bilateral procedure performed on both sides at the same operative session.

B. Do not submit two line items to report a bilateral procedure using modifier –50. Units when modifier –50 is reported is one (1).

C. Modifier -50 should NOT be used when the procedure is identified as “bilateral”. Refer to CPT code description. EXAMPLE: 27395— Lengthening of hamstring tendon, multiple, bilateral.

D. Modifier -50 should NOT be used when the procedure is identified as “unilateral or bilateral”. Refer to CPT code description. EXAMPLE: 52290 (Cystourethroscopy, with meatotomy, unilateral or bilateral).

E. Do not use a -50 modifier and HCPCS level II modifiers –RT or –LT for the same procedures.


QUESTIONS AND ANSWERS

1 Q: How should CPT or HCPCS codes such as 11400 (excision of benign lesion) be billed when they are performed on both sides of the body and are not CMS bilateral eligible?

A: An excision of a lesion is not truly bilateral. It should be billed with units, rather than the bilateral modifier.



2 Q: If a code has the term 'bilateral' in its definition, can it be reported with modifier 50?

A: No. For example, the CPT code 40843, Vestibuloplasty; posterior, bilateral includes the term 'bilateral' and is inherently a bilateral procedure. This code does not appear on Oxford's Bilateral Eligible List and may not be reported with modifier 50. To report unilateral performance of this procedure, use the appropriate unilateral CPT code 40842.

3 Q: If a code has the term 'bilateral' in its definition, yet the procedure was only performed on one side, how should this be reported?

A: If a code exists for the comparable unilateral procedure, report the appropriate unilateral code. If a code does not exist for the comparable unilateral procedure, report the bilateral code with modifier 52 appended. In this instance, modifiers LT or RT may be reported in another modifier position on the same claim line to describe which side the reduced procedure was performed on.

4 Q: Does one individual CPT or HCPCS code ever have more than one NPFS bilateral status indicator designation?

A: Yes, on occasion a code may have a global, professional, and technical component. The NPFS bilateral status indicator may vary between the components. When this occurs and one of the status indicators is bilateral eligible (e.g., NPFS bilateral indicator "1" or "3") and another is not bilateral eligible (e.g., NPFS bilateral indicator "0", "2" or "9"), the code is added to the Bilateral Eligible Procedures Policy List.


5 Q: What is the most appropriate way for a physician, hospital, ambulatory surgical center or other health care professional to bill Oxford for a Bilateral Procedure? 

A: The procedure should be billed on one line with a modifier 50 and one unit with the full charge for both procedures.

6 Q: What is the most appropriate way for a physician, hospital, ambulatory surgical center or other health care professional to report to Oxford for hand or foot codes that are on the Bilateral Eligible Procedures Policy List, but the same procedure is performed bilaterally on only one digit of each hand or foot?

A: If the same procedure is performed on the same digit on each hand or foot, report the procedure with modifier 50. If the same procedure is performed on a different digit or multiple digits of each hand or foot, report the procedure with the  ppropriate digit modifiers (e.g., FA or F1-9 [fingers], TA or T1-9 [toes]).

7 Q: What is the most appropriate way for a physician, hospital, ambulatory surgical center or other health care professional to report to Oxford for bilateral eligible spinal codes such as code 63035, Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure), if the procedure is performed on multiple levels of the same spinal region?

A: If the laminotomy is performed bilaterally, report code 63020 or 63030 with modifier 50 for the first interspace. If a laminotomy of a second interspace is performed bilaterally, use add-on codes to represent additional levels rather than sides. In this instance, report code 63035 with modifier 50. If a laminotomy of additional interspaces (3 or more) is performed bilaterally, report code 63035 with modifiers 50 and 59 or XS with the appropriate number of units.

8 Q: Does Oxford accept modifier 50 on all codes where the CPT book indicates coding guidelines to report modifier 50 when performing the procedure bilaterally? 

A: No. Oxford follows the Bilateral Procedures payment indicators "1" or "3" on the CMS NPFS to determine which codes are eligible for bilateral.

How many units of services should I submit when I am billing a bilateral surgical procedure with CPT modifier 50?

Answer:

The units of service you should submit depends on the Medicare Physician Fee Schedule bilateral indicator assigned to the procedure code.

If you are billing a bilateral surgical procedure, having a BILAT indicator of 1, you must submit CPT modifier 50, with 1 in the Quantity Billed field. Any other combination may result in a denial or an under payment.

If you are billing a bilateral procedure, having a BILAT indicator of 2, CPT modifier 50 or anatomic HCPCS modifiers (e.g. RT, LT, FA, F1-F9, TA, T1-T9, E1-E4), should not be submitted. These codes are considered bilateral and/or the code descriptions include possible multiple services. Any combination of these modifiers may result in a denial.

If you are billing a bilateral procedure, having a BILAT indicator of 3, CPT modifier 50 and anatomic HCPCS modifiers (e.g. RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) may be submitted with the number of services performed indicated by utilizing the Quantity Billed field as appropriate

Multiple Surgical Procedures

Multiple surgical procedures are procedures performed during the same operative session. Bilateral procedures are considered multiple procedures.

When multiple procedures are performed, the primary or major procedure is considered to be the procedure with the greatest value based on the allowable charge and may be reimbursed up to the allowable charge. The modifier used to report multiple procedures is 51. The modifier to report single and multiple bilateral procedures is 50, see below for more information on Modifier 50.

If a service includes a combination of procedures, one code should be used rather than reporting each procedure separately. If procedures are coded separately, Blue Cross may bundle the procedures and apply the appropriate allowable charge.

Secondary covered procedures are reimbursed up to 50 percent of the allowable charge.


Modifier 50 - Billing Single Bilateral Procedures

• Single Bilateral (Modifier 50) procedures can anatomically be done bilaterally only once per session.

• Multiple Bilateral (Modifier 50) procedures can anatomically be done bilaterally multiple times per session.

Correct submission of a bilateral procedure is the code on one line with Modifier 50 and “1” in the units field.


For all professional and facility claims, bilateral procedures are reimbursed as follows:

1. The primary bilateral procedures are reimbursed at 150 percent of the allowable charge.

2. The secondary bilateral procedures are reimbursed at 75 percent of the allowable charge.

Proper billing of bilateral procedures ensures correct reimbursement and eliminates the need for refund requests and payment adjustments.

Payment Implications

When modifier -50 is reported for surgical procedures, reimbursement is for two procedures. The pricer will apply the rules for calculating payment for multiple procedures. The provider is reimbursed at 150%  for non-radiology procedures. Radiology services are reimbursed at 200%.



Billing and Coding Guidelines

Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on the lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. Modifier 50 is used for bilateral procedures and this article provides information on claims submission for these procedures. CR 6526 implements the 150 percent payment adjustment for bilateral procedures.

Bilateral procedures are procedures performed on both sides of the body during the same operative session. Medicare makes payment for bilateral procedures based on lesser of the actual charges or 150 percent of the Medicare Physician Fee Schedule (MPFS) amount when the procedure is authorized as a bilateral procedure. CR 6526 implements the 150 percent payment adjustment for bilateral procedures. Medicare contractors use payment policy indicators associated with certain procedures in the MPFS in processing claims and determining payment.

Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure). Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifier is not reported.

If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator, 1) the procedure should be reported on a single line item with the 50 modifier and one service unit. Whenever the 50  modifier is appended, the appropriate number of service units is one. Modifiers LT (left side) and RT (right side) are not to be reported when the 50 modifier applies. Claims with the LT and RT modifiers will be returned to the provider (RTP) when modifier 50 applies

Invalid modifier combination denial:

• If a line item is denied for an invalid modifier combination, the claim cannot be adjuste based upon a phone call to Customer Service; a corrected claim will be needed. Records  may need to accompany the corrected claim in some situations.

• If you believe the invalid modifier denial is incorrect, please submit a written provider appeal and include coding guidelines supporting why the procedure code and modifier combination should be considered valid.

Specific combination examples:

Example # 1:
58720 = Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) This code is already priced as bilateral. Modifier 50 is not a valid modifier with this code.
58720-50 would deny for invalid modifier combination.


Example # 2:
27506 = Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws

Modifiers LT or RT would be valid for 27506 because there is a Right femur and a Left femur.

Harvard insurance Guidelines


• As defined in the CPT, Modifier 50 “Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five digit code.”

• Modifier 50 is used to report diagnostic, radiology and surgical procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

• Do not use Modifiers RT and LT when modifier 50 applies. A bilateral procedure is reported on one line, using modifier 50.

• Modifier 50 eligibility is based on procedure description, CPT guidelines, CMS directives and nationally recognized sources (e.g., Journal of AHIMA, CPT Assistant).

The modifier “50” is not applicable to:

• Procedures that are bilateral by definition.

• Procedures with descriptions including the terminology as “bilateral” or “unilateral.”



Harvard Pilgrim Reimburses

Bilateral services performed on both sides of the body during the same session or on the same day at 150% of the fee schedule allowed amount.

• Bilateral payment adjustment applies to all providers except for those providers contracted as facility surgery case rate and percent of charge reimbursement methods.

Bilateral Service Billing

Bilateral services performed on both sides of the body during the same session or on the same day must be billed on a single detail line with CPT and modifier 50 appended.

Multiple Modifiers Billing

Modifier that reduces the fee schedule/allowable amount must be billed in the primary modifier position, and modifier 50 in the secondary position.


Example 1

Professional component–26, bilateral procedure-50. Bill Modifier 1= 26, Modifier 2=50

Example 2

Technical component–TC, bilateral procedure-50. Bill Modifier 1= TC, Modifier 2=50

Bilateral Procedures Eligibility

Modifier 50 eligibility is based on procedure description, CPT guidelines, CMS directives and nationally recognized sources (e.g, Journal of AHIMA, CPT Assistant).



 In summary, Medicare contractors will:

• Return to Provider (RTP) bilateral procedures submitted on TOB 85X with RC 96X, 97X or 98X when the HCPCS/CPT code billed with the 50 modifier, has a payment policy indicator of ‘0’, ‘2’, or ‘9’.

o Payment Policy Indicator 0 – 150 percent payment adjustment for bilateral procedures does not apply. The bilateral procedure is inappropriate for codes in this category because of physiology or anatomy or the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

o Payment Policy Indicator 2 - 150 percent payment adjustment for bilateral procedures does not apply. The relative value units (RVUs) are  based on a bilateral procedure because the code descriptor states that the procedure is bilateral, the codes descriptor states that the procedure may be performed either unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure.

o Payment Policy Indicator 9 - concept does not apply.

• RTP bilateral procedures submitted on TOB 85X with RC 96X, 97X or 98X when the bilateral procedure code is billed with the RT and LT modifiers and the payment policy indicator is ‘1’ or ‘3’. This includes claims with a bilateral procedure and modifiers LT and RT on the same claim line or claims with the same bilateral procedure on two claim lines with the same line item date of service (LIDOS), one claim line with modifier RT and another claim line with modifier LT.

o Payment Policy Indicator 1 – 150 percent payment adjustment for bilateral procedures does apply.

o Payment Policy Indicator 3 - 150 percent payment adjustment for bilateral procedures does not apply. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.

• Pay for bilateral procedures on TOB 85X with RC 96X, 97X or 98X, one service unit and modifier 50 when the HCPCS/CPT code has a payment policy indicator of ‘1’ based on the lesser of the actual charges or the 150 percent payment adjustment for bilateral procedures as follows: (facility specific MPFS amount times bilateral procedure adjustment (150 percent) minus (deductible and coinsurance)) times 115 percent.



Pay for bilateral procedures on TOB 85X with RC 96X, 97X or 98X and modifier 50 and one service unit when the HCPCS/CPT code has a payment policy indicator of ‘3’ based on the lesser of the actual charges or 200 percent of the MPFS amount as follows: (facility specific MPFS amount times 200 percent (100 percent for each side) minus (deductible and coinsurance)) times 115 percent.

NOTE: Although the 150 percent payment adjustment does not apply to payment policy indicator ‘3’, modifier 50 may be billed with these procedures. When billed with the 50 modifier, payment is based on the lower of the actual charges or 200 percent of the MPFS amount.


Bilateral Procedure (Modifier 50) Payment Guidelines

*Surgery performed on both sides of the body at the same operative session or on the same day

*Always verify the B/S indicator for your procedure code based on the MPFS database file


*B/S indicator = 1

*Number of Service is 1

*Bill procedure code on one claim line

*Procedure  manual will specify if a code is unilateral, bilateral or unilateral or bilateral



Category            Indicator            Indicator Description


0
150% payment adjustment for bilateral procedures does not apply. Bilateral is inappropriate for codes in this category because of (a) physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.


1
150% payment adjustment for bilateral procedures applies. Modifier 50 appropriate if procedure is performed bilaterally. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g. with RT and LT modifiers or with a 2 in the units field), allows 150% of usual amount.

2
150% payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure.


3
200% payment adjustments for bilateral procedures apply. Modifier 50 appropriate if performed bilaterally.


A View of the MPFS (Bilateral Procedure)

Common Billing Errors (Mod 50)

*Modifier 50 used when code descriptions state unilateral or bilateral

*Billed inappropriately on codes that have a B/S indicator of “0” (Bilateral payment adjustment does not apply)


BCBSTX Reminder: Bilateral procedures – Modifier 50

Modifier 50 should be submitted only on those procedures that can be performed bilaterally. Bilateral procedures that are performed at the same operative session should be identified by adding a modifier 50 to the appropriate 5-digit CPT code.

Modifier 50 denotes a bilateral procedure (diagnostic, radiological or surgical) performed on both sides at the same operative session. Modifier 50 should not be used with procedures identified by their terminology as either "bilateral" or "unilateral or bilateral." Please report one unit, do not use modifiers RT and LT, and do not submit two line items. To view information on Blue Cross and Blue Shield of Texas’ (BCBSTX) Multiple Surgery Pricing, go to bcbstx.com/provider, under Standards & Requirements, go to General Reimbursement Information, All Product News, Multiple Surgery — Prof.

Please Note: Beginning April 1, 2012, recovery will be pursued on claims paid based on Modifier 50 inappropriate billing as described above.

Modifier 50 is used to report bilateral procedures that are performed during the same operative session by the same physician/professional provider in either separate operative areas (e.g. hands, feet, legs, arms, ears), or one (same) operative area (e.g. nose, eyes, breasts).

The current coding manual states that the intent of this modifier is to be appended to the appropriate unilateral procedure code as a one-line entry on the claim form indicating the procedure was performed bilaterally (two times).

An example of the appropriate use of Modifier 50:

Procedure Code Billed Amount Units/Days
64470-50 $####.## 1

When using Modifier 50 to indicate a procedure was performed bilaterally, the modifiers LT (Left) and RT (Right) should not be billed on the same service line. Modifiers LT or RT should be used to identify which one of the paired organs were operated on. Billing procedures as two lines of service using the left (LT) and right (RT) modifiers is not the same as identifying the procedure with Modifier 50. Modifier 50 is the coding practice of choice when reporting bilateral procedures. When determining reimbursement, the Blue Cross and Blue Shield of Texas/Blue Essentials, Blue Advantage HMO and Blue Premier Multiple Surgery Pricing Guidelines apply.

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