CPT or HCPCS codes that are bilateral in purpose or contain bilateral in their explanation should not be submitted with the bilateral modifier 50 or modifiers LT and RT because the code includes the bilateral process. CMS has amended its standards regarding the proper use and reporting of certain modifications.
Modifier 50 is utilized as a payment modifier instead of an informative modifier. Based on the procedure code and the BILAT SURG indication, the insertion of this modification may affect payment.
Servicing providers reporting under the same Tax ID number, whether identified as the same individual provider or another medical provider, are treated as one individual giving the reported health care services for this regulation.
Bilateral Indicator 0
The guidelines for bilateral surgery do not include applicable codes with a status indicator of 0. The bilateral indicator is ineffective for various reasons, including:
- It is not a bilateral bodily component, according to physiology.
- According to the code’s explanation, it is an existing bilateral operation.
- The surgery is rarely performed bilaterally. (These services do not fulfil the bilateral requirements.)
- Modifiers 50, LT, or RT should not be used with these codes.
- The payment adjustment of 150 percent for bilateral treatments does not apply.
Bilateral Indicator 1
- Bilateral Indicator 1 is used for the submission of bilateral billing claims. We require practitioners to record bilateral operations on one claim, with modifier 50 applied to the code, except CPT codes, which are essentially bilateral by definition (e.g., XXXX-50, billed with 1 unit). Failure to disclose bilateral procedures in this manner may result in inaccurate claim processing.
- Only when the operation is conducted unilaterally should these bilateral-indicator-1 processes be reported with either LT or RT and 1 unit of service. If the operation is conducted bilaterally, modifier 50 with 1 unit of service should be added to the procedure code.
- The payment adjustment of 150% is applicable to bilateral processes.
Bilateral Indicator 2
- Modifier 50 should not be used with these codes. These codes are already known to be executed bilaterally.
- The technique is fully stated in the code descriptors.
- According to the code description, the surgery can be conducted unilaterally or bilaterally.
- The surgery is usually done bilaterally.
- These codes should be charged with a maximum of one unit of service.
- If no unilateral CPT code occurs, report these operations with an LT or RT modifier. If a unilateral CPT code exists for the operation, it should be recorded with the LT or RT modifier and 1 unit of service.
- If there is no unilateral CPT code, modifier 52 should be added to the bilateral CPT code to reflect that a reduced service was delivered.
- Don’t apply the payment adjustment of 150 percent for bilateral treatments.
Bilateral Indicator 3
These codes should be reported with the relevant anatomical LT or RT modifier and one service unit. As an example:
- xxxxx-LT billed with a single unit on a single claim line.
- xxxxx-RT, invoiced on a distinct claim line with 1 unit.
- If conducted bilaterally, a practitioner may submit with modifier 50.
- The standard payment adjustment for bilateral treatments is not applicable.
Bilateral Indicator 9
The concept is inapplicable. The idea of bilateral surgery does not apply to codes with status indication 9. Modifiers 50, LT, or RT should not be used with these procedure codes.
Modifier 50 – Appropriate Application
Appropriate applications include:
- When conducting a bilateral operation in a single session, the Medicare Physician Fee Schedule Relative Value File (MPFSRVF), also known as the Medicare Physician Fee Schedule Database (MPFSDB) BILAT SURG indication is 1 or 3, use modifier 50.
- Add modifier 50 to report codes with a BILAT SURG indication and submit 1 unit of service on one line.
- Report codes with a BILAT SURG indication of 3 by attaching modifier 50 and utilizing one unit of service on one line or when the operation is performed on bilateral body parts.
- Modifier 50 is used to record bilateral operations done by the same physician during the same surgical session in different operative locations or in the same operative area.
- When utilizing modifier 50 to indicate a bilaterally conducted operation, do not bill modifiers LT and RT on the same service line. To identify which of the paired organs was operated on and apply the modifiers LT or RT. Billing processes using the LT and RT modifiers as two service lines is not the same as designating the procedure with modifier 50. Modifier 50 is the preferred coding technique to report bilateral operations.
Modifier 50 – Incorrect Application
Inappropriate use includes the following:
- When doing the treatment in separate locations on the same side of the body, do not utilize modifier 50.
- When the BILAT SURG indication is 0, 2, or 9, do not utilize modifier 50.
- When eliminating a lesion on the right arm and a lesion on the left arm, do not apply modifier 50. Make use of the RT and LT modifications.
- Modifier 50 should not be used with a procedure code specified as bilateral, unilateral, or bilateral in its CPT description.
- Reporting a bilateral procedure on two service lines by inserting modifier 50 to the second line of service is not permitted.
- Modifier 50 should not be used for operations involving midline organs such as the bladder or uterus and nasal septum.
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