Monday, June 22, 2015

Medicare physician fee schedule payment policy indicators - Modifier 50, 62, 66

Bilateral surgery - modifier 50

This field provides an indicator for services subject to a payment adjustment.
0 -- 150 percent payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code.
Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

1 -- 150 percent payment adjustment for bilateral procedures applies. If 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), contractors base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code

If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.
2 -- 150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), contractors base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code.

Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is usually performed as a bilateral procedure.
3 -- The usual payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), contractors base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If procedure is reported as a bilateral procedure and with other procedure codes on the same day, contractors determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules.

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.
9 -- Concept does not apply.

Assistant at surgery
This field provides an indicator for services where an assistant at surgery is never paid for per the CMS Internet-only manual.

0 -- Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
1 -- Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.
2 -- Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
9 -- Concept does not apply.

Co-surgeons - modifier 62
This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.
0 -- Co-surgeons not permitted for this procedure.
1 -- Co-surgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.
2 -- Co-surgeons permitted; no documentation required if two specialty requirements are met.
9 -- Concept does not apply.

Team surgeons - modifier 66
This field provides an indicator for services for which team surgeons may be paid.
0 -- Team surgeons not permitted for this procedure.
1 -- Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.
2 -- Team surgeons permitted; pay by report.
9 -- Concept does not apply.

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