Bilateral Procedures

Policy ID: NDRP-Surg-008_002

Section: Surgery

Effective Date: July 01, 2019

Revised Date: April 25, 2021

Last Reviewed: April 25, 2021

Table of Contents

Description
Definitions
Policy
Bilateral billing for services billed on a CMS-1500 Claim Form
Reimbursement for Bilateral Procedures on CMS-1500 Claim Form
Bilateral billing for services submitted on a UB-04 Claim Form with Enhanced Ambulatory Patient Groups (EAPGs) pricing
Bilateral billing for services submitted on a UB-04 Claim Form for claims not processing under EAPG Pricing
Edits
Limitations and Exclusions
Cross-Reference
History

Description:

This policy addresses reimbursement for bilateral procedures.

Definitions:

Definitions
Bilateral	Procedure normally performed on only one side of the body is performed on both sides during the same operative session
50 Modifier	Bilateral Procedure
59 Modifier	Distinct Procedural Service
RT Modifier	Right side
LT Modifier	Left side

Policy:

When "bilateral" or "unilateral or bilateral" is included within the procedure code description the bilateral reimbursement does not apply and the procedure 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 may be 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 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 and/or multiple endoscopy reduction(s).

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

Scenario	Services Rendered	Lines	CPT Code	Modifiers		# of Units
1	1 Bilateral Service Rendered	Line 1	XXXXX	50		1

2	1 Bilateral Service Rendered	Line 1	XXXXX	50		1
	1 Separate Distinct Unilateral Service Rendered	Line 2	XXXXX	59	RT or LT	1

3	1 Bilateral Service Rendered	Line 1	XXXXX	50		1
	1 Separate Distinct Bilateral Service Rendered	Line 2	XXXXX	50	59	1

Reimbursement for Bilateral Procedures on CMS-1500 Claim Form:

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.

CMS Definition for Bilateral Status Indicators
0	150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because of physiology anatomy or 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 a code is billed with the bilateral modifier (for example, with RT and LT modifiers or one line, one unit, and modifier 50 appended), payment is based on 150 percent of the fee schedule amount for a single code.
2	150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because these procedure codes are already bilateral.
3	150 percent payment adjustment for bilateral procedures does not apply. Payment will be based on the lower of 100 percent of the fee schedule for each side or actual charges for each side. Services in this category are generally radiology procedures or other diagnostic tests that are not subject to the special payment rules for other bilateral procedures.
9	150 percent payment adjustment for bilateral procedures does not apply. The bilateral adjustment is inappropriate for codes with this indicator because the concept does not apply.

Bilateral billing for services submitted on a UB-04 Claim Form with Enhanced Ambulatory Patient Groups (EAPGs) pricing

This policy applies to claims processed under EAPG pricing.

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

Scenario	Services Rendered	Lines	Revenue Code	CPT Code	Modifiers		# of Units
1	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX	50		1

2	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX	50		1
	1 Separate Distinct Unilateral Service Rendered	Line 2	XXXX	XXXXX	59	RT or LT	1

3	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX	50		1
	1 Separate Distinct Bilateral Service Rendered	Line 2	XXXX	XXXXX	50	59	1

Bilateral billing for services submitted on a UB-04 Claim Form for claims not processing under EAPG Pricing

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.

Scenario	Bilateral Services Rendered	Lines	Revenue Code	CPT Code	Modifiers		# of Units
1	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX			1
		Line 2	XXXX	XXXXX	50		1

2	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX			1
	1 Bilateral Service Rendered	Line 2	XXXX	XXXXX	50		1
	1 Separate Distinct Unilateral Service Rendered	Line 3	XXXX	XXXXX	59	RT or LT	1

3	1 Bilateral Service Rendered	Line 1	XXXX	XXXXX			1
	1 Bilateral Service Rendered	Line 2	XXXX	XXXXX	50		1
	1 Separate Distinct Bilateral Service Rendered	Line 3	XXXX	XXXXX	59		1
	Separate Distinct Bilateral Service Rendered	Line 4	XXXX	XXXXX	50	59	1

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 if the claim is not submitted with a valid repeat modifier.
Bilateral procedures performed during the same operative session as other surgical procedures may be subject to a multiple surgery reduction. The bilateral reduction applies first.

Note: BCBSND updates codes quarterly when made available by The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA). The official update of the Healthcare Common Procedure Coding System (HCPCS) for public use is located at https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update The official update of the AMA is located at https://www.ama-assn.org/.

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:

History:

Date	Updates
3/12/20	Added billing examples, Cross-References, and Limitations and Exclusions
5/13/20	Edit to Reimbursement section to apply only to CMS 1500
11/19/2020	Added updates to indicate UB-04 claim form submissions should be on one line with one unit effective with the implementation of the EAPG payment system. Removed reference to independent surgery reduction as that no longer applies as of 8/1/2020.
4/25/2021	Added a note that codes are updated quarterly.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.

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