Wiki Bilateral Procedures

[beatriz88b]

When billing mod -50 to any insurance carrier should I double the price when billing? Or does the payer already know it's a bilateral procedure once the modifier is appended? I've never heard about this before but a new coworker stated that for bilateral procedures pricing should always be doubled.

Thanks!!

 

[Cjcatty]

Modifier 50

Yes when you use the modifier 50, you need to double your price.

 

[mitchellde]

The federal register and numerous payer instructions state to use only the single code charge. The 50 modifier will signal the carrier to pay you at 150%.

 

[emcee101]

Since there are multiple ways to bill a bilateral procedure and different payers have different rules, there is not a "one-size-fits-all" answer.

Short answer though, if you are billing a unilateral code with modifier 50 to note that the procedure was performed bilaterally, you should increase your fee to 200% of the usual amount.

The payer knows that it is a bilateral procedure with the 50 appended, but if your fee amount is less than their increased allowable, your payment may be reduced to your charged amount.

Here a great article about billing for bilateral procedures, written for the Americal College of Surgeons.

http://bulletin.facs.org/2013/10/complexities-of-coding-bilateral-procedures/

 

[mitchellde]

I have never had an issue with any payer not paying correctly. The reimbursement is suppose to be 150% of the allowable. I have always used the single code charge.

 

[beatriz88b]

Thanks everyone. This was very helpful. So since the company I bill for bills at 300%-400% it's really not necessary to bill double the price. Because it's just raising the AR. Rt?

Thanks!

 

[DRCompliance]

If you look up specific code in Medicare fee schedule online, by modifier you can click on "detail" that will show you the specific bilateral modifier indicator (0,1,2,3,9), here are the explanations of indicators:
Indicator Number Description
0 The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator '0' with HCPCS modifier RT or LT or CPT modifier 50. Submission of these modifiers may result in a denial. Payment will be based on the lower of the actual charge for both sides or 100 percent of the fee schedule amount for a single code. The bilateral adjustment is not appropriate for codes with Indicator '0' because of (a) physiology or anatomy, or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for a bilateral procedure.
1 The 150 percent adjustment for bilateral procedures applies. Bilateral procedures must be reported with CPT modifier 50 and a quantity of '1'. When the code is reported with CPT modifier 50, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other 'multiple procedure' rules. Submission of modifiers other than 50 may result in a denial.
2 The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator 2 with HCPCS modifier RT or LT or CPT modifier 50. The Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charges by the physician for both sides or 100 percent of the fee schedule amount for a single code. If codes with bilateral indicator 2 are submitted with HCPCS modifier RT or LT or CPT modifier 50, the claim will be rejected as a 'billing error.' These claims must be corrected and resubmitted as new claims.
3 The 150 percent adjustment for bilateral procedures does not apply. Payment will be based on the lower of 100 percent of the fee schedule for each side or actual charges for each side. Report bilateral procedures with CPT modifier 50 and a quantity of '2' or report on separate detail lines with HCPCS modifiers RT and LT. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.
9 Concept does not apply. This indicator often appears in the CO SURG column for nonsurgical procedures.



Reference:

Complete definitions of bilateral indicators are available in CMS Pub. 100-04, Chapter 23 (PDF, 1.47 MB), in the Addendum following Section 90