Hello,
Do not bill ASC claims to Medicare with modifier -50. Please use anatomical modifiers and bill each side on 2 separate lines OR bill 2 units on 1 line. Usually billing each side on 2 separate lines is the preferred method. You will want to follow the Medicare ASC guidelines and not the OPPS guidelines. The Medicare ASC Guidelines do not allow for usage of modifier -50.
For Medicaid, Medicare Advantage Plans, and Commercial Payers, please review their billing and coding policies on their websites for further guidance as it will vary from payer to payer. For example, BlueCross BlueShield of Tennessee requires ASCs to bill 1 unit of service with modifier -50 instead of the usual 2 line items with -LT/-RT.
For most commercial payers, you may use modifiers -LT/-RT as typically it will result in higher reimbursement than if you were to bill the procedure with modifier -50 due to grouper fee reimbursement order. Most contracts have a 100%/50%/50%/etc. multiple procedure reduction like Medicare does. If a bilateral procedure is billed as the primary procedure, it will be reimbursed at 150% of the contracted fee. But when you bill a subsequent procedure with a modifier -50, it becomes 75% instead of 50% for each side (so it would then be 50% for left side and 25% for right side). I think some payers may keep it at 100% of the contracted fee for subsequent bilateral procedures. If the contract goes 100%/50%/25%, then the 3rd and subsequent billed bilateral procedures are paid at 50% of the contracted fee (25% for right, 25% for left).
You'll have to review your contract and the payer's guidelines.
Examples:
[With Modifier -50 w/ subsequent bilateral procedures processed @ 75% of contracted fee (50% for left, 25% for right)]
31255-50 Grouper 4 Fee: $400 @ 150% = $600 Allowed
30520 Grouper 5 Fee: $500 @ 50% = $250 Allowed
31267-50 Grouper 3 Fee: $300 @ 75% = $225 Allowed
31288-50 Grouper 2 Fee: $200 @ 75% = $150 Allowed
30930 Grouper 1 Fee: $100 @ 50% = $50 Allowed
Total Allowed: $1275
[With Modifier -50 w/ subsequent bilateral procedures processed @ 100% of contracted fee (50% for left, 50% for right)]
30520 Grouper 5 Fee: $500 @ 150% = $750 Allowed
31255-50 Grouper 4 Fee: $400 @ 100% = $400 Allowed
31267-50 Grouper 3 Fee: $300 @ 100% = $300 Allowed
31288-50 Grouper 2 Fee: $200 @ 100% = $200 Allowed
30930 Grouper 1 Fee: $100 @ 50% = $50 Allowed
Total Allowed: $1700
[Without Modifier -50]
30520 Grouper 5 Fee: $500 @ 100% = $500 Allowed
31255-LT Grouper 4 Fee: $400 @ 50% = $200 Allowed
31255-RT Grouper 4 Fee: $400 @ 50% = $200 Allowed
31267-LT Grouper 3 Fee: $300 @ 50% = $150 Allowed
31267-RT Grouper 3 Fee: $300 @ 50% = $150 Allowed
31288-LT Grouper 2 Fee: $200 @ 50% = $100 Allowed
31288-RT Grouper 2 Fee: $200 @ 50% = $100 Allowed
30930 Grouper 1 Fee: $100 @ 50% = $50 Allowed
Total Allowed: $1450
Isn't reimbursement methodology wonderful?
In my experience, I almost always bill -LT/-RT. There are very few payers that actually require ASCs to use modifier -50.
Sources:
Medicare Claims Processing Manual, Chapter 14 - Ambulatory Surgical Centers [40.5 - Payment for Multiple Procedures]:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf
BlueCross BlueShield of Tennessee Provider Manual [Pages 163 - 164 Outpatient Surgery]:
https://www.bcbst.com/providers/manuals/bcbstPAM.pdf