Description:

This policy addresses reimbursement for bilateral procedures.

Definitions:

Policy:

When "bilateral" or "unilateral or bilateral" is included within the procedure code description the bilateral reimbursement does not apply and should not be reported with modifiers 50, RT or LT. In some instances, procedure codes do not indicate which side of the body a procedure is performed. In those instances, the modifier RT or LT is used to indicate the side of the body on which a service or procedure is performed. Specifically, modifiers RT and LT should be used to identify procedures that can be performed on contralateral anatomic sites (such as bones, joints), paired organs (such as ears, eyes, nasal passages, kidneys, lungs, or ovaries), or extremities (such as arms or legs). Modifiers RT and LT should be used to indicate that the procedure is performed on only one side of the body.

Bilateral billing for services billed on a CMS-1500 Claim Form:

When reporting modifier 50 to indicate a bilateral procedure, report the procedure on one claim line with one service unit.  Bilateral procedures performed during the same operative session as other surgical procedures may be subject to a multiple surgery reduction.

Note: The scenarios below list examples of correct billing for bilateral services rendered based on the number of times the procedure was performed.

Bilateral billing for services submitted on a UB-04:

Bilateral services should be reported on two lines of service. The number of units on each line should be one. Modifier 50 may be appended to one of the lines, but a bilateral procedure cannot be billed as only one line with modifier 50. Bilateral procedures performed during the same operative session as other surgical procedures may be subject to a multiple surgery reduction.

Note: The scenarios below list examples of correct billing for bilateral services rendered based on the number of times the procedure was performed.

Edits:

Certain edits apply to bilateral services

• Procedure narratives containing the word “bilateral” or are inherently considered bilateral will be denied if submitted with a 50 modifier. The denial will state incorrect procedure/modifier combination.
• If more than one line of the same procedure code is submitted on a CMS-1500 Claim Form, one with the 50 modifier and one without a modifier, the line without a modifier will be denied as a duplicate.
• Bilateral procedures performed during the same operative session as other surgical procedures may be subject to a multiple surgery or independent surgery reduction.

Reimbursement for Bilateral Procedures:

Reimbursement for bilateral services is based on the modifier(s) reported, as well as, the Centers for Medicare & Medicaid Services (CMS) bilateral status indicators found on the CMS National Physician Fee Schedule (NPFS) Relative Value Unit (RVU) File. When CMS indicates modifier 50 is not billable, the RT and LT modifier(s) are also not billable. The bilateral indicators and payment rules are listed below.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.
• Blue Cross reserves the right to process bilateral services differently from Medicare.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross-Reference:

CMS NPFS RVU File

BCBSND Reimbursement Policies:

• Modifiers 25, 59, XE, XP, XS and XU
• Multiple Surgeries
• Correct Coding Guidelines

History: