Modifier 50; Bilateral Procedure

Policy No: 108
Originally Created: 08/01/2009
Section: Modifiers
Last Reviewed: 02/01/2019
Last Revised: 05/01/2015
Approved: 02/07/2019
Effective Date: 04/01/2019

This policy applies only to physicians and other qualified health care professionals.

Definitions

Modifier 50
Current Procedural Terminology (CPT®) modifier 50 represents a service or procedure performed on both sides of the body during the same session.

Bilateral Adjustment

The Centers for Medicare & Medicaid Services (CMS) Bilateral Procedure Indicators (BI) are found in the CMS National Physician Fee Schedule Relative Value Unit (RVU) File. Values which are currently in the CMS file are:

0 - 150% payment adjustment for bilateral procedures does not apply.
1 - 150% payment adjustment for bilateral procedures applies.
2 - 150% payment adjustment does not apply.
3 - The usual payment adjustment for bilateral procedures does not apply.
9 - Concept does not apply

Policy statement

Our health plan considers codes with CMS Bilateral Procedure Indicators of 1 and 3 eligible for bilateral adjustment. Reimbursement for codes with Bilateral Procedure Indicator of 1 will be 150% of the fee schedule amount. Reimbursement for codes with Bilateral Procedure Indicator of 3 will be 200% of the fee schedule amount.

Codes with CMS Bilateral Procedure Indicators (BI) of 0 or 2 should not be billed with modifier 50.

In the event there is a conflict between CMS and American Medical Association (AMA), AMA guidelines take precedence. For example, CMS RVU file indicates a BI indicator of 2 on code 69210. However, in 2014 the code descriptor has been changed from removal impacted cerumen, from 1 or both ears to unilateral. AMA specifically noted to report 69210 with modifier 50 when performed bilaterally. Our health plan will therefore accept 69210-50 as a valid HCPCS/modifier combination.

When modifier 50 is valid, and the procedure is performed bilaterally, our health plan requires billing the procedure code on one line with modifier 50 appended to the procedure code. Units of service should be "1". Claims where the same procedure is submitted with two lines or two units and anatomic modifiers will be denied for incorrect coding.

References

American Medical Association. Appendix A: Modifiers, Current Procedural Terminology (CPT). AMA Press

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.