Coding for bilateral procedures can be confusing. Many payers accept CPT modifier 50 as an indicator of a bilateral procedure, but they differ in how they apply it to their coding and payment policies.
First, let’s look at what CPT says: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code.
Below is a brief look at the policies of top payers. But first, NOTE: Under ICD-10, many diagnosis codes are anatomically specific. Take that into consideration when deciding which modifier would be appropriate. For example:
Example 1
25515 Treat Fracture of Radius
DX: S52.302A Unspecified fracture of shaft of RIGHT radius, initial encounter
Modifier 50 or LT would not be appropriate in the above situation
Example 2
25515 Treat Fracture of Radius
DX:
S52.301A Unspecified fracture of shaft of LEFT radius, initial encounter
S52.302A Unspecified fracture of shaft of RIGHT radius, initial encounter
Modifier 50 would be appropriate.
PAYER POLICIES
Medicare
Definition: Medicare contractor Novitas Solutions defines bilateral surgeries as procedures performed on both sides of the body during the same operative session or on the same day. The Centers for Medicare & Medicaid Services has defined codes subject to the bilateral payment rule. To verify if a code is subject to the bilateral payment policy, search the code on the Medicare Physician Fee Schedule using this tool. (Need help? See How to Use the Searchable Medicare Physician Fee Schedule Booklet).
Coding notes: Report the procedure code with modifier 50. Report a “1” in the number-of-services field. For example, if you are billing for a bilateral mastectomy, you would report CPT code 19303 (Mastectomy, simple, complete) with the modifier. You would report the service as a single line item: 19303 50.
Do not report modifier 50 with procedure codes whose terminology is indicative of unilateral or bilateral services because these codes are bilateral by definition. Examples are code 27395 (Lengthening of hamstring tendon; multiple, bilateral) and code 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral).
How it pays: Medicare pays claims reporting bilateral procedures based on 150% of the Medicare Physician Fee Schedule fee amount. The limiting charge is 115% of that amount. Certain procedures are not applicable to the 150% payment rule for bilateral procedures; payment is based on 100% of the fee schedule for each side, e.g., ophthalmoscopy codes 92225 and 92226. When performed bilaterally, these codes should be reported with modifiers RT (right)-LT (left) or modifier 50 to ensure proper payment. Procedure codes containing the terms “bilateral” or “unilateral or bilateral” in their definitions are not subject to bilateral pricing. Payment for these services is based on 100% of the fee schedule for a surgical code.
Resources: Modifier 50 Fact Sheet on the Novitas Solutions website and How to Use the MPFS Medicare Look-Up Tool
Medicaid
Coding notes: When a bilateral procedure is performed and an appropriate bilateral code is not available, use a unilateral code. Bill the unilateral code twice with a quantity of 1 for each code. For all procedures, use modifiers LT and RT as appropriate. For example, bilateral application of short leg cast is billed as follows:
Procedure Code Modifier
29405 LT
29405 RT
Resources: This policy is in the TMHP Texas Medicaid Provider Procedures Manual, 9.2.70.4. Check the manual for instruction about coding for specific procedures.
Aetna
Definition: A surgical procedure is considered bilateral when the same procedure is performed on both sides of the body. Common anatomical sites for bilateral surgical procedures are extremities, eyes, ears, and breasts.
Coding note: For commercial plans, Aetna pays 150% of the Medicare Physician Fee Schedule amount for a bilateral surgical or nonsurgical procedure. Bilateral surgical and nonsurgical procedures are reported as a single code billed (1) with modifier 50, (2) twice on the same day with RT and LT modifiers, or (3) with 2 units.
For Medicare plans, Aetna pays 150% of the fee schedule amount for a bilateral surgical procedure. Bilateral surgical procedure codes must appear on two separate claim lines. Aetna pays 100% of the recognized charge or negotiated fee for the claim line with the surgical procedure code and no modifier, and 50% of the recognized charge or negotiated fee for the claim line with the surgical procedure code and modifier 50.
How it pays: Aetna determines the order of multiple surgical procedures on the basis of the relative value units of each procedure for the appropriate place of service (facility versus nonfacility) under the Medicare Physician Fee Schedule. When a surgeon performs bilateral surgery, or a combination of both bilateral and multiple surgeries, Aetna calculates the allowable benefit as follows (in the same manner as for multiple surgery):
100% for the procedure with the highest RVU +
50% for the procedure with the second highest RVU +
25% for each subsequent procedure.
Resources: Availity
BCBSTX
Definition: Bilateral procedures are those performed during the same operative session on identical anatomic sites, aspects, or organs.
Coding notes: Blue Cross and Blue Shield of Texas (BCBSTX) follows the CPT guideline, which is to append modifier 50 to the appropriate unilateral procedure code as a one-line entry on the claim form indicating the procedure was performed bilaterally (two times).
Do not use modifier 50 when the procedure code descriptor indicates bilateral or when RT (right) and LT (left) would be applicable to the services. Use modifiers LT or RT to identify which one of the paired organs was operated on. Billing procedures as two lines of service using the LT and RT modifiers is not the same as identifying the procedure with modifier 50. Modifier 50 is the coding practice of choice when reporting bilateral procedures to BCBSTX.
How it pays: For Blue Choice PPO and Blue High Performance Network, multiple surgery pricing guidelines apply: When two or more surgical procedures are performed on the same date of service within the same operative session by the same physician at the same place of treatment, the primary procedure is eligible for payment at 100% of the fee schedule or other allowed amount, and the secondary procedure and other subsequent procedures at 50%.
Resources: CPCP023 Modifier Reference Policy (effective June 26, 2023) and CPCP015 Multiple Surgical Procedures
Cigna
Definition: Modifier 50 is used to report procedures performed on both sides of the body (mirror image) during the same operative session. It is only applicable to services and/or procedures performed on identical anatomical sites, aspects, or organs.
Coding notes: List the procedure code once with modifier 50. For surgical codes, list the number of units as “1”; for nonsurgical codes, list the number of units as “2.” Do not use modifier 50 to report surgical procedures identified by their CPT descriptor as bilateral or unilateral. Do not use modifier 50 with modifiers RT and LT. If the CPT code descriptor indicates a bilateral procedure (and there is no CPT code for unilateral procedure), and the procedure was only performed on one side, it is appropriate to use modifiers RT or LT with modifier 52 (Reduced Services). RT and LT may be used without modifier 50 but not in addition to modifier 50.
If there are CPT codes specific to the procedure, one for unilateral and one for bilateral, the bilateral code would be appropriate for use if the procedures were performed during the same operative session by the same physician. CPT codes that can be reported with modifier 50, when appropriate, are 10021-69990 (Surgery), 70010-79999 (Radiology), and 90281-99199 (Medicine). Note: Not all codes within these ranges are applicable.
How it pays: Cigna pays at 100% of the fee schedule or usual and customary (U&C)/maximum reimbursable charge (MRC) for the first surgical procedure and 50% for the second surgical procedure.
Nonsurgical codes eligible for bilateral payment are paid at 200% of the fee schedule or other allowed amount when billed with modifier 50 and “1” unit on one line. Nonsurgical codes are paid at 100% of the fee schedule or other allowed amount when billed with HCPCS modifiers RT/LT on separate lines with “1” unit per line.
.Multiple, bilateral procedures follow multiple surgery guidelines outlined in Cigna’s modifier 51 policy (with the exception of multiple radiology imaging services for contiguous body parts).
Resources: Cigna Bilateral Procedures Policy and Cigna Reimbursement Policy
Humana
Definition: Humana refers to American Medical Association guidelines: “Modifier 50 is used to report bilateral procedures that are performed at the same operative session” (by the same physician). “Bilateral procedures are procedures typically performed on both sides of the body.”
Coding notes: Humana recognizes bilateral modifier 50 or modifiers RT and LT appended to procedure codes as applicable for commercial and Medicare Advantage plans. Humana’s code edits require the use of these anatomical modifiers to designate the area or part of the body on which the procedure is performed.
How it pays: Humana recognizes as two services but processes as one unit a single claim line containing an inherently unilateral CPT code billed with modifier 50. Humana pays such a claim at 150% of the allowable. When claims are billed with two or more of the same inherently unilateral CPT codes where any line contains the modifier 50, the first line containing modifier 50 is paid at 150%, and all subsequent lines with the same CPT code are denied.
If an inherently bilateral procedure is submitted with a modifier 50, Humana pays at 100%. If a code is categorized as both unilateral/bilateral and submitted with a modifier 50, Humana considers the code as an inherently bilateral code and pays at 100%.
The applicable bilateral surgery increase (150%) will be applied before multiple surgery reduction logic based on highest base allowable. Commercial standard multiple surgery policy is 100/50/25.
Resources: Humana’s Payment Policy ̶ Bilateral Surgery
United Healthcare
Definition: Bilateral procedures are those that can be performed on both sides of the body during the same session by the same individual physician.
Coding notes: Procedure codes bilateral in their intent or with bilateral written in their description should not be reported with the bilateral modifier 50, or modifiers LT and RT, because the code is inclusive of the bilateral procedure. The UnitedHealthcare (UHC) Bilateral Eligible Procedures Policy List is developed based on the Medicare Physician Fee Schedule relative value file status indicators.
How it pays: A unilateral surgical code reported with modifier 50 is eligible for payment at 150% of the allowable, with one side paid at 100% and the other side at 50%. When other reducible procedure codes are reported on the same date of service, an additional multiple procedure/imaging reduction may or may not be applied to the line paid at 100%, depending on whether another procedure code is ranked as primary or not. A nonsurgical code reported with modifier 50 will be eligible for payment at 100% of the allowable amount for each side for a sum of 200% of the allowable amount.
Resources: UHC Bilateral Procedures Policy
If you have questions about billing and coding or payer policies, contact the reimbursement specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Reimbursement Review and Resolution Service (formerly known as the Hassle Factor Log program) to help resolve insurance-related problems.
Revised Oct. 4, 2023