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).
- 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.
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 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.
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.
- 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: firstname.lastname@example.org or call us at: 888-357-3226.