Description
This policy provides direction on Blue Cross Blue Shield of North Dakota (BCBSND) reimbursement of bilateral services.
Policy
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
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0
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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.
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1
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150 percent payment adjustment for bilateral procedures applies.
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2
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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.
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3
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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.
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9
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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.
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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, LT or RT. In some instances, procedure codes do not indicate which side of the body a procedure is performed. In those instances, the modifier LT or RT may be used to indicate the side of the body on which a service or procedure is performed. Specifically, modifiers LT or RT 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).
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.
Cross References
History
Date
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Updates
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3/12/2020
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Added billing examples, Cross-References, and Limitations and Exclusions
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5/13/2020
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Edit to Reimbursement section to apply only to CMS 1500
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11/19/2020
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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.
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4/25/2021
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Added a note that codes are updated quarterly.
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09/30/2021
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Removed billing tables and updated language. Updated the format and added more references.
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1/24/2022
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Corrected cross referenced policy name from Modifiers 25, 59, XE, XP, XS & XU
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6/30/2022
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Corrected policy number from NDPR-GC-008 to NDRP-GC-008
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