Mod 108 MA - Modifier 50; Bilateral Procedure - Medicare Advantage

Modifier 50; Bilateral Procedure - Medicare Advantage

Policy No: 108
Originally Created: 08/01/2009
Section: Modifiers
Last Reviewed: 01/01/2019
Last Revised: 03/01/2017
Approved: 01/17/2019
Effective Date: 02/01/2019

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

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.

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

Our health plan considers codes with CMS Bilateral Procedure Indicators of 1 and 3 eligible for bilateral adjustment:

  • Endoscopic codes with Bilateral Procedure Indicator of 1 will be 150% of the fee schedule amount.
  • Non endoscopic codes with Bilateral Procedure indicator of 1 will be 150% of the fee schedule amount.
  • Codes with Bilateral Procedure Indicator of 3 will be 200% of the fee schedule amount.

References

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

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.