Policy Statement
Our health plan considers codes with CMS Bilateral Procedure Indicators of 1 and 3 eligible for bilateral adjustment. Reimbursement for codes with Bilateral Procedure Indicator of 1 will be 150% of the fee schedule amount. Reimbursement for codes with Bilateral Procedure Indicator of 3 will be 200% of the fee schedule amount.
Codes with CMS Bilateral Procedure Indicators of 0 or 2 should not be billed with modifier 50.
In the event there is a conflict between CMS and American Medical Association (AMA), CMS guidelines take precedence, with the exception of code 69210. For the exception of code 69210, the CMS NPFSRVF indicates code 69210 has a Bilateral Procedure indicator of 2. However, in 2014, the code descriptor has been changed from removal of impacted cerumen, from one or both ears to unilateral. AMA specifically noted to report 69210 with modifier 50, when performed bilaterally. Our health plan will therefore accept 69210-50 as a valid HCPCS/modifier combination for reporting. However, 69210-50 will not be eligible for 150% adjustment.
When modifier 50 is valid, and the procedure is performed bilaterally, our health plan requires billing the procedure code on one line with modifier 50 appended to the procedure code. Units of service should be “1”. Claims where the same procedure is submitted with two lines or two units and anatomic modifiers (i.e., -RT and -LT) will be denied for incorrect coding.
Our health plan will reimburse bilateral procedures when billed as single surgeon, surgeon-assistant combination, or co-surgeons. When billing as a surgeon-assistant combination, only one surgeon may be considered the primary surgeon for that procedure. Bilateral services, even if performed simultaneously, will be reimbursed as co-surgeons (with modifiers 50 and 62 appended to both claims) or as primary surgeon and assistant surgeon. Plan will not provide reimbursement when components of a procedure are billed by more than a single primary surgeon.
Procedure code/modifier combinations that are considered not valid for our health plan’s use will be denied.
References
- American Medical Association. “Appendix A – Modifiers”. Current Procedural Terminology (CPT®). Chicago: AMA Press
- Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule Relative Value File
Cross References
- Adm 129 - Correct Coding Guidelines
- Mod 109 - Modifiers 80, 81, 82, AS; Assistant at Surgery
- Mod 113 - Modifier 62; Two Surgeons/Co-Surgeons
