Billing Guidelines for Bilateral Surgeries

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Billing Guidelines for Bilateral Surgeries

• Bilateral Surgeries Billing
• Bilateral surgeries are procedures performed on
  both sides of the body during the same operative
  session or on the same day. Medicare makes the
  payment for bilateral procedures based on the
  lesser of the actual charges or 150 percent of
  the Medicare Physician Fee Schedule (MPFS) amount
  when the procedure is authorized as a bilateral
  procedure. This Change Request implements the 150
  percent payment adjustment for bilateral
  procedures. The billing guidelines for bilateral
  surgeries are as follows
• Billing Guidelines for Bilateral Surgeries
• If a procedure is not identified by its
  terminology as a bilateral procedure (or
  unilateral or bilateral), physicians must report
  the procedure with the modifier -50. They
  report such procedures as a single line item. If
  a procedure is identified by the terminology as
  bilateral (or unilateral or bilateral), as in
  codes 27395 and 52290, physicians do not report
  the procedure with the modifier -50. The
  terminology for some procedure codes includes the
  terms bilateral (e.g., code 27395 Lengthening
  of the hamstring tendon multiple, bilateral.) or
  unilateral or bilateral (e.g., code 52290
  cystourethroscopy with ureteral meatotomy,
  unilateral or bilateral).

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Billing Guidelines for Bilateral Surgeries

• The payment adjustment rules for bilateral
  surgeries do not apply to procedures identified
  by CPT as bilateral or unilateral or
  bilateral since the fee schedule reflects any
  additional work required for bilateral surgeries.
• Modifier 50 applies to bilateral procedures
  performed on both sides of the body during the
  same operative session. When a procedure is
  identified by the terminology as bilateral or
  unilateral, the 50 modifier is not reported.
• If a procedure is authorized for the 150 percent
  payment adjustment for bilateral procedures, the
  procedure shall be reported on a single line item
  with the 50 modifier and one service unit.
  Whenever the 50 modifier is appended, the
  appropriate number of service units is one.
• Modifiers LT (left side) and RT (right side)
  shall not be reported when the 50 modifier
  applies. Claims with the LT and RT modifiers
  shall be returned to the provider when modifier
  50 applies.
• If a procedure can be billed as bilateral but is
  not authorized for the 150 percent payment
  adjustment for bilateral procedures, the
  procedure shall be reported on a single line item
  with the 50 modifier and one service unit.
  Payment is made based on the lesser of the actual
  charges or 100 percent of the MPFS amount for
  each side of the body.
• Ambulatory Surgical Centers (ASCs) cannot append
  the 50 modifier on bilateral surgery claims.
  Bilateral procedures must be reported on two
  separate lines appending the appropriate RT
  and/or LT modifier.

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Billing Guidelines for Bilateral Surgeries

• 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, payers require
  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

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Billing Guidelines for Bilateral Surgeries

• 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 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.

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Billing Guidelines for Bilateral Surgeries

• 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.
• Incorrect Use of Modifier 50
• 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 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.

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Billing Guidelines for Bilateral Surgeries

• 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.
• Medical Billers and Coders (MBC) is a leading
  medical billing company providing complete
  medical billing and coding services. We
  referred Medicare Claims Processing Manual
  Chapter 12 to share billing guidelines for
  bilateral surgeries.
• For surgery billing and coding assistance, email
  us at info_at_medicalbillersandcoders.com or call
  us at 888-357-3226.