Modifier 50; Bilateral Procedure

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: Group and Individual

This policy applies only to physicians, 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 File (NPFSRVF). 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.

Codes with CMS Bilateral Procedure Indicators 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), CMS guidelines take precedence with the exception of code 69210. For the exception of code 69210, the CMS NPFSRVF indicates code 69210 has a Bilateral Procedure indicator of 2. However, in 2014, the code descriptor has been changed from removal of impacted cerumen, from one 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 for reporting. However, 69210-50 will not be eligible for 150% adjustment.

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.

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