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Tip: Bill for bilateral procedures

Ambulatory Surgery Reimbursement Update, June 17, 2008

If a surgical procedure is by (CPT) definition unilateral, but a physician performs it bilaterally, ASCs should report the CPT code on the claim form in a bilateral manner.

The policies individual payers have for the use of modifiers to report bilateral procedures can vary widely, so ASCs should check with each payer to which they submit claims for guidance on how best to report them. For example, modifier -50 identifies a procedure performed identically on opposite sides of the body (i.e., mirror image). But some payers prefer the use of the -RT anatomic modifier on one code and the -LT anatomic modifier on the other. But be sure not to mix the use of -50 and -RT or -LT modifiers on the same code! And be consistent in the method you use as you report codes for different payers.

If a surgical code is by definition bilateral, report the CPT procedure code once—with no modifier—even if the physician performs the procedure on both sides. Don’t use bilateral modifiers on those CPT codes with descriptions designated as “bilateral” or “unilateral or bilateral”. And remember, bilateral modifiers are not needed on the 10000-section skin/Integumentary system codes.

Generally, you may bill bilateral procedures in the following ways: 

  • Bill the same code as two line items, using the same code on each line. Use the -RT modifier on one code and the -LT modifier on the other code.
  • Bill the bilateral procedures as two line items, using the same code on each line. Include no modifier on the first code and a modifier -50 on the second line item.
  • Bill the procedure as a single line item on the claim form with a modifier -50 on the procedure code. Be sure to double the facility fee when using this method.
  • Bill the same code as two line items with no modifiers. You may use this method when submitting the claim to Medicare.
  • Bill the procedure as a single line item on the claim form with no modifier on the procedure code. Use a “2” in the Units column on the claim form. Be sure to double the facility fee when using this method. You may use this method when submitting a claim to Medicare.

Note: Since the changes in the Medicare program for ASC billing became effective in 2008, Medicare directs ASCs to bill bilateral procedures using the last two methods in the list above. If you experience claim denials using either of the last two methods recommended by CMS, try the first option (using the RT and -LT anatomic modifiers) instead.

This tip is brought to you by Ellis Medical Consulting, Inc.

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