Modifier 50; Bilateral Procedure - Medicare Advantage
Policy No: 108
Originally Created: 08/01/2009
Last Reviewed: 01/01/2019
Last Revised: 03/01/2017
Effective Date: 02/01/2019
This policy applies only to physicians and other qualified health care professionals.
Current Procedural Terminology (CPT®) modifier 50 represents a service or procedure performed on both sides of the body during the same session.
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
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.
American Medical Association. Appendix A: Modifiers, Current Procedural Terminology (CPT). AMA Press