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Bilateral Procedures

Policy ID: NDRP-Surg-008
Section: Surgery
Effective Date: July 01, 2019
Last Reviewed: March 17, 2020

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 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.

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

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.

Scenario

Bilateral Services Rendered

Lines

CPT Code

Modifiers

# of Units

1

1 Bilateral Service Rendered

Line 1

XXXXX

 

 

1

 

 

Line 2

XXXXX

50

 

1

 

 

 

 

 

 

 

2

1 Bilateral Service Rendered

Line 1

XXXXX

 

 

1

 

1 Bilateral Service Rendered

Line 2

XXXXX

50

 

1

 

1 Separate Distinct Unilateral Service Rendered

Line 3

XXXXX

59

RT or LT

1

 

 

 

 

 

 

 

3

1 Bilateral Service Rendered

Line 1

XXXXX

 

 

1

 

1 Bilateral Service Rendered

Line 2

XXXXX

50

 

1

 

1 Separate Distinct Bilateral Service Rendered

Line 3

XXXXX

59

 

1

 

Separate Distinct Bilateral Service Rendered

Line 4

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.
  • 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.

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.

 

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