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Q/A: Correct use of modifier -50

APCs Weekly Monitor, April 23, 2010

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Q: Can you explain use of CPT modifier -50, bilateral procedure and the reporting for outpatient surgery? Sometimes we understand and sometimes it is a mystery. What can we use to assist in this endeavor and remain compliant with OPPS guidelines?

A: First, understanding the narrative of CPT codes is important. Don’t report modifier -50 if a narrative states “one or both,” “bilateral,” or “unilateral or bilateral.” With that said, modifier-50 applies to any procedure performed on both sides during the same session. The best resource for understanding the proper reporting of modifier-50 for hospitals is the Outpatient Code Editor (OCE), specifically Appendix A (Bilateral Procedure Logic) and Appendix D (Computation of Discounting Fraction). Three OCE edits are dedicated to correct reporting of modifier -50:

• Edit 16—Multiple bilateral procedures without modifier -50
• Edit 17—Inappropriate specification of bilateral procedure
• Edit 74—Units greater than one for bilateral procedure with modifier -50

Each of these causes a “Return To Provider” (RTP) disposition of the claim.

CMS uses the Medicare Physicians’ Fee Schedule database to determine the correct application of modifier -50 for hospitals to ensure proper discounting and reimbursement. The column labeled “Bilateral Surgery Indicator” indicates whether you may report the procedure as a bilateral procedure. If there is a “0” in the column for the CPT code, Medicare does not allow reporting of modifier-50. If there is a “1” in the column for the CPT code, you may report modifier-50 and Medicare will recognize the procedure for bilateral reimbursement.

Procedure with status indicator “T” will be paid at 150% to account for the 50% reduction for the second procedure under the multiple procedure reduction rules. However, CMS uses a formula that results in 75% payment for each procedure. Procedures with a status indicator other than “T” will be paid at 200%.

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