Modifier 50 identifies the same procedures that are performed as a bilateral service. The procedure should be billed on one line with modifier 50 and one unit with the full charge for both procedures. A procedure code submitted with modifier 50 is a reimbursable service as set forth in this policy only when it is listed on the Oxford Bilateral Eligible Policy List.
When a CPT or HCPCS code is reported with modifier 50 and the code is not listed on the Bilateral Eligible Procedures Policy List, the code will not be reimbursed.
CPT or HCPCS codes with ‘bilateral’ or ‘unilateral or bilateral’ written in the description are not on Oxford’s Bilateral Eligible Procedures Policy List and will not be reimbursed with modifier 50.
There are are instances in which a bilateral service may be performed on multiple sites and not just bilaterally. In those instances, use modifier 59 Distinct Procedural Service or XS Separate Structure to report the additional units beyond the bilateral services performed indicating that the services were performed on a different site or organ system. Medical record documentation must support the use of modifier 59 or XS.
Procedure Codes with the Term “Bilateral” in the Description When CPT or HCPCS codes with “bilateral” or “unilateral or bilateral” written in the description are reported, special consideration will be given when reported with modifiers LT or RT.
When a CPT or HCPCS procedure code exists for both a unilateral and a Bilateral Procedure, select the code that best represents the procedure. For example: 40842 Vestibuloplasty; posterior, unilateral and 40843 Vestibuloplasty; posterior, bilateral.
Codes with “Bilateral” in the Description Policy List
Consistent with CPT guidelines, if a unilateral procedure has not been defined by CPT or HCPCS and only a bilateral description of a procedure exists, report the code with “bilateral” in the description with modifier 52 (reduced services) when the procedure is performed unilaterally. For more information on reimbursement for reduced services, see Oxford’s Reduced Services policy.
For Oxford purposes, when both modifiers LT and RT are reported separately for codes with “bilateral” in the description, only one charge will be eligible for reimbursement up to the respective Maximum Frequency per Day (MFD) value as the procedure is inherently bilateral. For additional information, refer to the Questions and Answers section, Q&A3. For more information on maximum frequency per day values, see Oxford’s Maximum Frequency Per Day policy.
When a procedure with “unilateral or bilateral” written in the description is performed unilaterally, then the CPT or HCPCS procedure code need not be reported with modifier 52 since the procedure description already indicates that the service can be performed either unilaterally or bilaterally. For example: 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure).
Codes with “Unilateral or Bilateral” in the Description Policy List
The use of modifiers LT or RT will be recognized as informational only when the procedure with “unilateral or bilateral” in description is performed on only one side. Consistent with CMS guidelines, when both modifiers LT and RT are reported separately on the same day by the same individual physician, hospital, ambulatory surgical center or other health care professional, only one charge will be eligible for reimbursement up to the maximum frequency per day limit.
For maximum frequency per day limits, see Oxford’s Maximum Frequency Per Day policy. Modifier Definitions Modifier Description 50 Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate five digit code.
Description
Bilateral services are procedures performed on both sides of the body during the same session or on the same day.
The HCPCS modifiers -LT and -RT are used when the procedure is valid for a modifier -50 procedure but the procedure is only performed on one side.
• As defined in the CPT, Modifier 50 “Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five digit code.”
• Modifier 50 is used to report diagnostic, radiology and surgical procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.
• Do not use Modifiers RT and LT when modifier 50 applies. A bilateral procedure is reported on one line, using modifier 50.
• Modifier 50 eligibility is based on procedure description, CPT guidelines, CMS directives and nationally recognized sources (e.g., Journal of AHIMA, CPT Assistant).
The modifier “50” is not applicable to:
• Procedures that are bilateral by definition.
• Procedures with descriptions including the terminology as “bilateral” or “unilateral.”
Harvard Pilgrim Reimburses1
Bilateral services performed on both sides of the body during the same session or on the same day at 150% of the fee schedule allowed amount.
• Bilateral payment adjustment applies to all providers except for those providers contracted as facility surgery case rate and percent of charge reimbursement methods.
Bilateral Service Billing
Bilateral services performed on both sides of the body during the same session or on the same day must be billed on a single detail line with CPT and modifier 50 appended.
Multiple Modifiers Billing
Modifier that reduces the fee schedule/allowable amount must be billed in the primary modifier position, and modifier 50 in the secondary position.
REIMBURSEMENT GUIDELINES
Bilateral Eligible List
The Oxford Bilateral Eligible Procedures Policy List is developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.
All codes in the NPFS with the “bilateral” status indicators “1” or “3” are considered by Oxford to be eligible for bilateral services as indicated by the bilateral modifier 50.
When a bilateral eligible code with a bilateral indicator of “1” is reported with modifier 50 and is subject to reductions under the Multiple Procedures policy, the code will be eligible for reimbursement at 150% of the allowable amount not to exceed billed charges for a single procedure code, with one side reimbursed at 100% and the other side reimbursed at 50%. When other reducible procedure codes are reported on the same date of service, an additional multiple procedure reduction may or may not be applied to the line paid at 100% depending on whether another procedure code is ranked as primary or not.
When a bilateral eligible code with a bilateral indicator of “3” is reported with modifier 50 and is not subject to reductions under the Multiple Procedure Policy, the code will be eligible for reimbursement at 100% of the allowable amount for each side for a sum of 200% of the allowable amount not to exceed billed charges.
Multiple Procedure Reduction
Eligible Bilateral Procedures on the Oxford Bilateral Eligible Procedures Policy List may be subject to multiple procedure reductions as defined in Oxford’s Multiple Procedures policy. In order to fully understand Oxford’s reimbursement rules for eligible Bilateral Procedures, refer to the Multiple Procedures policy in conjunction with this policy.
Recent Comments