December 6, 2018
Bilateral surgeries are procedures performed on identical anatomic sites on both sides of the body during the same operative session by the same provider. When coding these procedures that contain the phrases “bilateral” or “unilateral,” it’s important to use of modifiers 50- bilateral procedure, modifier LT – left side or modifier RT – right side.
Premera primarily determines whether a code is eligible or billable as a bilateral procedure based on the current CMS National Physician Fee Schedule Relative Value Guide, “Bilateral Surgery” indicator flag of 1 – Payment adjustment does apply.”
If a procedure code description includes the terminology “bilateral” or “bilateral or unilateral,” the use of modifier 50 isn’t needed because it’s in the code description. Physician and Ambulatory Surgery Centers should bill the code on a single line with no modifier 50 appended to the code. Some examples of bilateral or unilateral codes include:
- Code 27395 – Lengthening of hamstring tendon; multiple tendons, bilateral
- Code 52290 – Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral
If a procedure code indicates it’s a unilateral procedure and the service is conducted on the identical anatomic sites on opposite sides of the body, the appropriate way to bill varies.
If the procedure was performed on BOTH the right and left sides of the body, a physician must report the procedure with the modifier 50 on a single line to indicate the procedure was performed on BOTH sides. An Ambulatory Surgery Center would report the procedure code on two lines, one line with the modifier LT and a second line with the modifier RT. If the procedure was performed only on a single anatomic side, then only the LT or the RT modifier would be applied to indicate the side of the body where the procedure was performed.
Some examples of codes that don’t identify an anatomic side include:
- Code 15833 – Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
- Code 23600 – Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation
If a code is defined as a “bilateral procedure” on the CMS National Physician Fee Schedule with flag indicator “1 – Payment adjustment does apply” and is billed with modifiers LT and RT, the procedure will be reimbursed as a bilateral service. For further information, refer to the “Modifier 50 – Bilateral Procedure” Payment Policy.