Bilateral Surgeries and CPT Modifier 50

Published 05/19/2020

Background

Reimbursement for bilateral surgeries is determined using the Medicare Physician Fee Schedule Database (MPFSDB). The MPFSDB defines procedures that may be submitted as "bilateral" and how reimbursement is calculated.

  • The "bilateral surgery indicator" in the MPFSDB indicates how the bilateral surgery must be submitted to Medicare

  • To access this database, refer to the Physician Fee Schedule CMS web page 

  • The concept of a "bilateral surgery" applies when a procedure is performed on both sides of the body during the same operative session or on the same day

  • Modifier 50 should not be submitted on Ambulatory Surgery Center (ASC) services. See IOM Publication 100-4, Chapter 14, Section 40.5 for bilateral ASC submissions.

Bilateral Surgery Indicators and Claim Submission


Bilateral Surgery Indicator
Payment Basis
Claim Submission
0
The lower of the actual submitted charge for both procedures or 100% of the fee schedule amount for a single procedure.

Payment is not increased for these procedures because physiology or anatomy are not appropriate (e.g., surgeries on the large intestine), or because the code descriptor specifies that it is a unilateral procedure and there is an existing code for a bilateral procedure.
Submit the surgery with a quantity of 1.

Do not submit these procedures with CPT modifier 50.
1
The lower of the actual submitted charge or 150% of the fee schedule amount.
Submit the surgery on a single detail line with CPT modifier 50 and a quantity of 1.

Tip: Check any applicable Local Coverage Determinations (LCDs) for additional information on modifiers.
2
The lower of the actual submitted charge for both procedures or 100% of the fee schedule amount for a single procedure.

The fee schedule amount is already based on the procedure being performed bilaterally.

The fee schedule takes into account the bilateral nature of these procedures because the code descriptor states that either:
  1. The procedure is bilateral
  2. The procedure may be performed unilaterally or bilaterally
  3. The procedure is usually performed as a bilateral procedure
Submit the surgery with a quantity of 1.

Do not submit these procedures with CPT modifier 50 or HCPCS modifiers RT or LT.
3
The lower of the actual submitted charge for both procedures or 100% of the fee schedule amount for each side.

Most procedures with a bilateral surgery indicator of "3" are radiology procedures or other diagnostic tests, which are not subject to the special payment rules for other bilateral procedures.
Submit the surgery or procedure on a single detail line with CPT modifier 50 and a quantity of 2.

Option: Submit the surgery on 2 detail lines, one with HCPCS modifier RT and one with HCPCS modifier LT.
9
The concept of "bilateral surgery" does not apply.
Submit the surgery or procedure with a quantity of 1.

Do not submit these procedures with CPT modifier 50.

Palmetto GBA does not require additional documentation to be submitted with the claim supporting use of CPT modifier 50.

  • Documentation maintained in the patient’s medical record must support the use of this modifier, along with other procedural and diagnosis information submitted on the claim

Coding Examples (for 2019 dates of service)

Procedure(s)
Performed
CPT code
Bilateral Surgery Indicator
Modifier(s)
Quantity
Integumentary System: 
2 benign hyperkeratotic lesions removed, one from each arm
11056
0
None
1
Digestive System:
Partial colectomy, with removal of more than 1 segment of the colon
44140
0
None
2
Nervous System:
Laminectomy of 3 cervical segments
63015
0
None
1
Musculoskeletal System:
Bilateral injection of steroids for carpal tunnel syndrome
20526
1
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
1
Musculoskeletal System:
Bilateral shoulder arthroscopy, with synovial biopsy on both
29805
1
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
1
Urinary System:
Bilateral surgical laparoscopy for ureterolithotomy
50945
1
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
1
Eye and Ocular Adnexa:
Cataract removal, both eyes
66984
1
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
1
Integumentary System:
Blepharoplasty, both upper eyelids
15822
1
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
1
Respiratory System:
Control of nosebleed, both nostrils
30905
2
None
1
Respiratory System:
Bilateral lung transplant
32853
2
None
1
Radiology:
X-rays of both shoulders
73040
3
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
2, or
1 on each line
Radiology:
X-rays of both feet
73620
3
CPT modifier 50 or
submit as 2 separate detail lines with HCPCS modifiers RT and LT
2, or
1 on each line
 
 

References

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