Reimbursements

Category:

Bilateral Procedures

Reimbursement Policy: NDRP-Surg-008
Topic: Surgery
Effective Date: July 1, 2019
Last Reviewed:
July 22, 2019

Description:

This policy addresses reimbursement for bilateral procedures.

Definitions:

Modifier 50 – Bilateral Procedure
Modifier RT and LT – Designate the side of the body the procedure was performed on.
Bilateral – Procedure normally performed on only one side of the body is performed on both sides during the same operative session.

Policy:

Bilateral billing for services billed on a CMS-1500 Claim Form

When reporting procedures that were performed bilaterally, you must report the correct number of services to correspond with the modifier(s) you report.

When reporting procedures that were performed bilaterally, report the correct number of services corresponding with the modifier(s) reported.

Right and Left Modifiers (RT and LT)

  • When reporting bilateral services on two lines of service, report modifier RT on one line and modifier LT on the other. The number of services on each line should be 1. This option is selected when the services occur on the same day but not during the same operative session. Do not use modifiers RT and LT when modifier -50 is appropriate.

Bilateral Modifier (-50)

  • Modifier -50 is used for bilateral procedures that are performed at the same operative session. When reporting modifier -50 to indicate a bilateral procedure, report the procedure on one claim line. The number of services should be 1*.

*Note – Previous BCBSND direction was to report 2 units of service with modifier -50.

Multiple services on the same side of body

  • When reporting multiple services performed on the same side of the body, report the appropriate modifier for laterality (RT or LT) and the applicable number of unit(s)
  • When multiple services for the same side of the body are reported on separate claim lines, append modifier -76 on the second line with the same procedure code for correct payment to be made.

The CPT descriptors for some procedures specify the procedure is bilateral. In such cases, the bilateral modifier should not be used. Blue Cross requires bilateral procedures be submitted on one line appended with the -50 modifier. Blue Cross reserves the right to process bilateral services differently from Medicare.

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
  • If more than one line of the same procedure code is submitted, 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.

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.

Reimbursement for Bilateral Procedures

Reimbursement for bilateral services is based on the modifier(s) reported as well as the CMS bilateral indicator found on the Medicare Physician Fee Schedule. When CMS indicates modifier -50 is not billable, the LT and RT modifier(s) are also not billable. The bilateral indicators along with their payment rules are listed below.

  • 0 – 150 percent payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or with modifiers RT and LT, BCBSND will base payment for the two sides on the lower of:
    • The total actual charge for both sides or
    • 100 percent of the fee schedule amount for a single code

*Note: Codes with this identifier are typically unilateral, and modifier -50 is not billable.

  • 1-150 percent payment adjustment for bilateral procedures applies. If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the unit’s field), BCBSND will base payment for these codes when reported as bilateral procedures on the lower of:
    • The total actual charge for both sides or
    • 150 percent of the fee schedule amount for a single code
  • 2-150 percent payment adjustment for bilateral procedure does not apply. Fees are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the unit field), BCBSND will base payment for both sides on the lower of:
    • The total actual charges by the physician for both sides or
    • 100 percent of the fee schedule amount for a single code.

*Note: Codes with this identifier are typically identified as bilateral in the code description and modifier -50 is not billable.

  • 3 – The usual payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and Lt modifiers or with a 2 in the unit’s field), BCBSND will base payment for each side or organ or site of a paired organ on the lower of:
    • The actual charge for each side or
    • 100% of the fee schedule amount for each side.

*Note: Codes with this identifier are typically radiology procedures or other diagnostic tests not subject to bilateral rules.

  • 9- Codes with this identifier do not apply to the bilateral concept. Modifier -50 is not billable.

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.