This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement of bilateral services.
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. The bilateral indicators and payment rules are listed below.
Bilateral Status Indicators
Bilateral surgery rules do not apply to codes with a status indicator 0. The bilateral indicator is inappropriate for reasons such as:
- Physiology; is not a bilateral body part.
- The codes description states it is an existing bilateral procedure.
- The procedure is not commonly performed as bilateral. (These services do not meet the bilateral criteria.)
These codes should not be billed with modifiers 50, LT or RT.
The 150 percent payment adjustment for bilateral procedures does not apply.
Valid for bilateral billing claim submission, except for CPT codes inherently bilateral by definition.
Reporting Bilateral Indicator 1 procedures with either LT or RT and 1 unit of service is appropriate only if the procedure is being performed unilaterally. If the procedure is performed bilaterally, modifier 50 should be appended to the procedure code with 1 unit of service.
The 150 percent payment adjustment for bilateral procedures applies.
These codes should not be billed with modifier 50. These codes are already established as being performed bilaterally:
- The code descriptors specifically state the procedure is bilateral.
- The code descriptor states the procedure may be performed either unilaterally or bilaterally.
- The procedure is usually performed as bilateral.
These codes should be billed with no more than 1 unit of service.
Reporting these procedures with either an LT or RT modifier is appropriate if no unilateral CPT code exists. If a unilateral CPT code exists for the procedure, the unilateral CPT code should be reported with either the LT or RT modifier, with 1 unit of service.
150 percent payment adjustment for bilateral procedures does not apply.
The usual 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.
Concept does not apply. The bilateral adjustment is inappropriate for codes with this indicator because the concept does not apply. Codes that have this indicator are generally codes that are not specific to a certain side of the body.
Note: BCBSND updates Current Procedural Terminology (CPT) & Healthcare Common Procedure Coding System (HCPCS) codes on a quarterly basis.
Coding & Billing Guidelines
BCBSND has different coding and billing requirements for bilateral services billed on the professional CMS-1500 Claim Form and UB-04 Claims paid with Enhanced Ambulatory Patient Groups (EAPGs) versus the facility UB04 Claim Form not paid with EAPGs.
CMS-1500 Claim Form and UB-04 Claim Form priced with EAPG
- Bilateral Procedure
- One claim line
- One unit of service
- Modifier 50
UB-04 Claim Form priced with other than EAPG
- Bilateral Procedure
- Two claim lines
- One unit of service each
- Modifier 50 appended to one of the lines
Note: If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, the bilateral adjustment is applied before applying any applicable multiple procedure rules.
Limitations & 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.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Added billing examples, Cross-References, and Limitations and Exclusions
Edit to Reimbursement section to apply only to CMS 1500
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.
Added a note that codes are updated quarterly.
Removed billing tables and updated language. Updated the format and added more references.
Corrected cross referenced policy name from Modifiers 25, 59, XE, XP, XS & XU
Corrected policy number from NDPR-GC-008 to NDRP-GC-008
|Reviewed policy, corrected cross referenced Correct Coding Guidelines title, updated bilateral modifier use for each indicator and added Correct Coding Guidelines – Medicaid to cross references.