Sunday, June 13, 2010

Bilateral Services and CPT Modifier 50

Bilateral services are procedures performed on both sides of the body during the same operative session
or on the same day. The modifier "50" is not applicable to procedures that are bilateral by definition or
their descriptions include the terminology as "bilateral" or "unilateral".

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

Modifier "50" should follow the procedure code in Item 24d of the CMS-1500 claim form, or in the
equivalent electronic field, when services are rendered bilaterally (unless the code does not require this
modifier as described above).

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. The quantity entry to
use when modifier -50 is reported is one.

NOTE: Use of modifiers applies to services/procedures performed on the same calendar
day.

Reimbursement for bilateral services is determined using the Medicare Physician Fee Schedule
Database (MPFSDB). The MPFSDB defines procedures that may be submitted as “bilateral” and how
reimbursement is calculated.

Bilateral Surgery Indicators and Claim Submission
Bilateral Indicator                            Definition   
                                             
0                                   150% payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or with RT and LT, the payment is based on the two sides on the lower
of the total charges for both sides or 100% of the fee schedule for a single code.

1                                  150% payment adjustment for bilateral procedure applies. If the code is billed with the bilateral modifier (50), the payment is based on the lower of the total charges for both sides or
150% of the fee schedule for a single code.

2                                 150% payment adjustment does not apply. Relative value units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with a
modifier 50 or twice on the same day by any other means, the payment is based on both sides of the total actual charge by the physicianfor both sides or 100% of the fee schedule for a single code. The RVUs are based on the bilateral procedure because the code descriptor specifically states that the procedure is
bilateral, the code descriptor states the procedure may be performed unilaterally or bilaterally, or the procedure is usually performed as a bilateral procedure.

3                                    The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day, payment is based on
each side or organ or site of a paired organ on the lower actual charge for each side of 100% of the fee schedule amount for each side. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.

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