Date Issued: 11/7/2014
CPT or HCPCS codes that are bilateral in intent or have bilateral in their description should not be reported with the bilateral modifier 50 or modifiers LT and RT because the code is inclusive of the bilateral procedure. CMS has updated its policies concerning the appropriate use and reporting of these modifiers.
For this policy, servicing practitioners reporting under the same Tax ID number, whether designated the same individual physician or another health care professional, are considered as one individual rendering the reported health care services.
Modifier 50 is used as a payment modifier, rather than an informational modifier. The addition of this modifier may affect payment depending on the procedure code and the BILAT SURG indicator.
Bilateral Indicator 0
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.
Bilateral Indicator 1
Valid for bilateral billing claim submission. With the exception of CPT codes inherently bilateral by definition, EmblemHealth requires practitioners to report procedures performed bilaterally on one claim line with modifier 50 appended to the code (e.g., xxxxx-50, billed with 1 unit). Failure to report bilateral procedures in this way may result in incorrect processing of claims.
Reporting these 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.
Bilateral Indicator 2
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. If no unilateral CPT code exists, modifier 52 should be appended to the bilateral CPT code to indicate a reduced service was performed.
The 150 percent payment adjustment for bilateral procedures does not apply.
Bilateral Indicator 3
These codes should be reported with the appropriate anatomical LT or RT modifier, with one unit of service for each. For example:
- xxxxx-LT, billed with 1 unit on one claim line
- xxxxx-RT, billed with 1 unit on a separate claim line
A practitioner can submit with modifier 50, if performed bilaterally.
The usual payment adjustment for bilateral procedures does not apply.
Bilateral Indicator 9
Concept does not apply. Bilateral surgery concept does not apply to codes with status indicator 9. These procedure codes should not be billed with modifiers 50, LT or RT (e.g., xxxxx, billed with 1 unit).
Modifier 50 – Correct Usage
Appropriate usage includes:
- Use modifier 50 when performing a bilateral procedure during one session and the Medicare Physician Fee Schedule Relative Value File (MPFSRVF), also known at the Medicare Physician Fee Schedule Database (MPFSDB) BILAT SURG indicator is 1 or 3.
- Report codes with a BILAT SURG indicator of 1 by appending modifier 50 and submit 1 unit of service on one line.
- Report codes with a BILAT SURG indicator of 3 either by appending modifier 50 using 1 unit of service on one line or when performing the procedure on bilateral body parts.
- Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
- Do not bill modifiers LT and RT on the same service line when using modifier 50 to indicate a bilaterally performed procedure. Modifier LT or RT should be used to identify which of the paired organs was operated on. Billing procedures as two lines of service using the LT and RT modifiers is not the same as identifying the procedure with modifier 50. Modifier 50 is the coding practice of choice when reporting bilateral procedures.
Modifier 50 – Incorrect Usage
Inappropriate usage includes:
- Do not use modifier 50 when performing the procedure on different areas of the same side of the body.
- Do not use modifier 50 when the BILAT SURG indicator is 0, 2 or 9.
- Do not use modifier 50 when removing a lesion on the right arm and a lesion on the left arm. Use the RT and LT modifiers.
- Do not use modifier 50 with a procedure code that is described as bilateral, or unilateral or bilateral, in its CPT description.
- Do not report a bilateral procedure on two lines of service by appending modifier 50 to the second line of service.
- Do not submit modifier 50 on procedures for midline organs such as the bladder, uterus, esophagus and nasal septum.
