CMS Clarifies Bilateral Surgical Procedures and MUEs

CMS Clarifies Bilateral Surgical Procedures and MUEs

Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable, and the Centers for Medicare & Medicaid Services (CMS) has expanded its instructions to make it all a little more clear. 

MUEs and  Bilateral Surgery

CMS points out in MLN Matters SE1422 Revised that providers and suppliers billing bilateral procedures using the Medicare Physician Fee Schedule (MPFS) must provide a 50 modifier and One Unit of Service (UOS) on successful claims. 

Coding claims for surgical procedures performed bilaterally depends on:

  • The CPT/HCPCS Level II code descriptor
  • The Bilateral Indicator assigned to the CPT/HCPCS Level II code (that is, whether special payment rules apply)
  • The nature of the service

The National Correct Coding Initiative (NCCI) manual specifies that coders use modifier 50 when reporting bilateral surgical procedures as a single UOS. The NCCI manual warns that MUE edits based on established CMS policies may limit units of service and are predicated on the assumption that claims are coded in accordance with these Medicare instructions. Consequently, many bilateral procedures have an MUE value of 1.

Here are the bilateral indicators, as explained by CMS:

Bilateral Indicator What Does this Bilateral Indicator Mean?
 

 

 

 

 

0

 

No bilateral payment adjustment 150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

 

 

 

1

 

150% Bilateral payment adjustment 150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

 

 

Bilateral Indicator What Does this Bilateral Indicator Mean?
 

 

 

 

 

 

2

Bilateral procedure 150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of

$100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.

 

 

 

 

3

No bilateral payment adjustment The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries

Examples of Incorrect Coding

CMS provides some examples to help illustrate correct coding. 

 

 

Bilateral Indicator

 

Expected Units of Service if performed bilaterally

 

Modifier based on Laterality

 

 

Second Modifier

 

 

HCPCS code descriptor and Explanation of Incorrect Coding

 

 

 

 

1

 

 

 

 

1

 

 

 

 

RT

 

 

 

 

LT

23515 Open treatment of clavicular fracture, includes internal fixation, when performed. The code descriptor does not identify this procedure as a bilateral procedure (or unilateral or bilateral), so when performed bilaterally at the same operative session physicians must report the procedure with modifier “-50” as a single line item using one UOS. Do not use modifiers RT and LT when modifier -50 applies.
 

 

 

2

 

 

 

1

 

 

 

LT

52290 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral. The code descriptor identifies this procedure as a unilateral or bilateral procedure, so when performed bilaterally at the same operative session report one UOS as a single line item and do not report the procedure with modifier “-50”. Do not report the procedure using two line items using RT and LT modifiers.
 

 

 

 

2

 

 

 

 

1

 

 

 

 

RT

52290 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral. The code descriptor identifies this procedure as a unilateral or bilateral procedure, so when performed bilaterally at the same operative session report one UOS as a single line item and do not report the procedure with modifier “-50”. Do not report the procedure using two line items using RT and LT modifiers.
 

 

 

2

 

 

 

2

64488 Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed). The code descriptor identifies this procedure as a bilateral procedure, so when performed bilaterally at the same operative session report one UOS as a single line item. Do not report two UOS.
 

 

 

2

 

 

 

1

 

 

 

50

64488 Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed). The code descriptor identifies this procedure as a bilateral procedure, so when performed bilaterally at the same operative session report one UOS as a single line item. Do not report the procedure with modifier “-50”.

 

Brad Ericson

Brad Ericson

Director of Publishing at AAPC
Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

About Has 317 Posts

Brad Ericson, MPC, CPC, COSC, has been director of publishing for more than 10 years. Before AAPC he was at Optum for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

One Response to “CMS Clarifies Bilateral Surgical Procedures and MUEs”

  1. Dana Nevarez says:

    very clearly written, perfect examples

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