Modifier 50; Bilateral Procedure - Medicare Advantage

Policy No: 108
Originally Created: 08/01/2009
Section: Modifiers
Last Reviewed: 07/01/2023
Last Revised: 07/01/2021
Approved: 07/13/2023
Effective Date: 08/01/2023
Policy Applies to: Medicare Advantage

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

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 (NPFSRVF) File. Values, which are currently in the CMS NPFSRVF, 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

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.

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 (i.e., -RT and -LT) will be denied for incorrect coding.

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

Our health plan will reimburse bilateral procedures when billed as single surgeon, surgeon-assistant combination, or co-surgeons. When billing as a surgeon-assistant combination, only one surgeon may be considered the primary surgeon for that procedure. Bilateral services, even if performed simultaneously, will be reimbursed as co-surgeons (with modifiers 50 and 62 appended to both claims) or as primary surgeon and assistant surgeon. Plan will not provide reimbursement when components of a procedure are billed by more than a single primary surgeon.

Procedure code/modifier combinations that are considered not valid for our health plan’s use will be denied.

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

Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule Relative Value File

Correct Coding Guidelines

Modifiers 80, 81, 82, AS; Assistant at Surgery

Modifier 62; Two Surgeons/Co-Surgeons