Bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate CPT or HCPCS code. The procedure should be billed on one line with modifier 50 and one unit with the full charge for both procedures. A procedure code submitted with modifier 50 is a reimbursable service as set forth in this policy only when it is listed on the UnitedHealthcare Bilateral Eligible Procedures Policy List.
How to Bill bilateral procedures?
Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on TOB 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure).
Can ASC bill for DME?
SNF billing Guide If the ASC furnishes items of implantable DME to patients, the ASC bills and receives a single payment from the local contractor for the covered surgical procedure and the implantable device, as long as the implantable device does not have pass-through status under OPPS.
How does Medicare affect medical billing?
Obamacare’s Affect on Medical Billing and Coding
- Increased Demand for Work. One of the undeniable facts about Obamacare is that more Americans will have health insurance, which means that demand for coding and billing professionals is bound ...
- Cumbersome Government-Related Processing Issues. ...
- Increased Medicare Efficiency. ...
- Job Outlook. ...
What are the requirements for Medicare billing?
- The regular physician is unavailable to provide the service.
- The beneficiary has arranged or seeks to receive the services from the regular physician.
- The locum tenens is NOT an employee of the regular physician.
- The regular physician pays the locum tenens physician on a per diem or fee-for-service basis.
What is the correct CPT modifier for bilateral procedures?
modifier 50Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
How many units do you bill for a bilateral procedure?
Bilateral surgical and nonsurgical procedures are reported as a single code billed (1) with modifier 50, (2) twice on the same day with RT and LT modifiers, or (3) with 2 units.
What is the typical reimbursement rate for bilateral procedures?
150%Bilateral procedure fee adjustments are applied to procedure codes with a bilateral procedure indicator of “1” on the MPFSDB. These procedures will be reimbursed at 150% of the usual applicable fee schedule rate.
What is the modifier for bilateral?
Modifier 50Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifier is not reported.
How do you bill bilateral injections?
Question: What is the appropriate way to bill a bilateral injection and drug?67028 -50, 1 unit and double the amount. Submit with the bilateral diagnosis.For the drug, double the units and bill the bilateral diagnosis.
How do I bill bilateral knee injections to Medicare?
Indicate which knee was injected by using the RT (right) or LT (left) modifier (FAO-10 electronically) on the injection procedure (CPT 20610). Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.
How do you bill bilateral procedures to Blue Cross?
Blue Cross requires bilateral procedures be submitted on one line appended with the -50 modifier. Blue Cross does not publish a list of surgeries that are considered bilateral.
How do I know if a CPT code is bilateral?
What does 2 mean? If the code has an indicator of two, it is a bilateral procedure code. You would not need to add a modifier 50 because the code is already bilateral. A code with this indicator lets the insurance company know that both sides were done.
What are the bilateral CPT codes?
Bilateral Surgeries and CPT Modifier 50Procedure(s) PerformedCPT codeBilateral Surgery IndicatorIntegumentary System: Blepharoplasty, both upper eyelids158221Respiratory System: Control of nosebleed, both nostrils309052Respiratory System: Bilateral lung transplant328532Radiology: X-rays of both shoulders7304038 more rows•May 19, 2020
Does Medicare accept modifier LT and RT?
Several DME MAC LCD-related Policy Articles require the use of the RT and LT modifiers for certain HCPCS codes. The right (RT) and left (LT) modifiers must be used when billing two of same item or accessory on the same date of service and the items are being used bilaterally.
Does modifier 59 go before RT?
Contributor. different shoulders, modifiers RT and LT should be used, not modifier 59. LT and RT have not effect on the actual processing of the claim for payment, because they are informational.
How do I bill Medicare 20610 bilateral?
10:4114:03CPT 20610 Billing Scenarios - YouTubeYouTubeStart of suggested clipEnd of suggested clipIf the doctor did two joint injections one injection was to the right shoulder and the otherMoreIf the doctor did two joint injections one injection was to the right shoulder and the other injection was to the left knee modifiers rt and lt can be used.
Identifying Bilateral Codes
In some cases, descriptors for procedure codes can be included within the description itself.
MPFS Indicator "B" - Descriptors
CPT 27331 has a bilateral indicator of a 1, which means bilateral surgery rules apply. If the 50 modifier is appended to the CPT with 1 unit billed, Medicare will allow 150%. If billed with 2 units, it states the procedure was completed 4 times and will be denied as unprocessable.
Billing Guidelines
A procedure that is not identified by its descriptor as a bilateral procedure (or unilateral or bilateral), indicates the physician must report the procedure with the 50 modifier. For Medicare billing purposes, such procedures should be reported as a single line item.
Processing Guidelines
We (Noridian) will process claims for bilateral surgeries according to the presence of the 50 modifier on the CMS-1500 claim form, or its electronic submission, or of the same code on separate lines, one line with LT modifier and the other with the RT modifier.
Resources
Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40.7
Why is bilateral adjustment inappropriate?
The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1.
What is MUE in medical terms?
Medically Unlikely Edits (MUEs) may render certain claim lines for bilateral surgical procedures unpayable, and the Centers for Medicare & Medicaid Services (CMS) has expanded its instructions to make it all a little more clear.
Who is Brad Ericson?
Brad Ericson. Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor.He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979.
Is RVU bilateral or bilateral?
The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure. 3.
Why is coding for bilateral procedures so challenging?
Furthermore, coding for bilateral procedures is particularly challenging because it is defined in various ways.
Why is bilateral adjustment inappropriate?
The bilateral adjustment is inappropriate for codes with this indicator because of physiology or anatomy or because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1-indicator: 150 percent payment adjustment for bilateral procedures applies.
What is the unit code for Medicare?
Reporting codes that can be performed bilaterally and are not otherwise identified. Medicare and payors that follow Medicare rules, including United Healthcare, Aetna, Humana, and Cigna, require that the code be billed on one line, the unit be listed as 1, and modifier 50 be appended: Example: XXXXX–50, Units = 1.
What is a BCBS?
For example, the Blue Cross Blue Shield (BCBS) Association is composed of multiple companies, and many of them have different local coding and coverage guidelines for bilateral procedures. For a list of local BCBS Association companies, go to www.bcbs.com/about-the-companies/; bilateral procedure rules will be listed under “Provider” ...
Do providers have to wait for denials?
Providers should not wait for denials to identify a payor’s bilateral procedures claim form policy. It is important to verify a payor’s reporting preference to avoid payment denials because some payors may require one- or two-line entry or the use of HCPCS Level II RT and LT modifiers.
Can third party payers report bilateral procedures?
Third-party payors have different policies for reporting bilateral procedures on the claim form. It may be difficult to know how payors expect bilateral procedures to be represented on the claim form. Providers should not wait for denials to identify a payor’s bilateral procedures claim form policy.
What is the overlap between surgical and pre-procedure?
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap of the pre-procedure ...
What is the modifier indicator in CCI?
Each CCI code pair edit includes a correct coding modifier indicator of “0” or “1,” as indicated by a superscript placed to the right of the column 2 code.
Can you use modifiers for separate procedures?
If, however, the two procedures are separate and distinct, you may be able to use a modifier to override the edit and be paid for both procedures. Separate, distinct procedures may include: different session. different procedure or surgery. different site or organ system.
Does CPT have multiple procedures?
Multiple procedure rule does not apply to all CPT® codes.
Can NCCI codes be bundled?
In some cases, the National Correct Coding Initiative (NCCI) may impose edits that “bundle” codes to one another. If the NCCI lists any two codes as “mutually exclusive,” or pairs them as “column 1” and “column 2” codes, the procedures are bundled and normally are not reported together.
What is a CPT code?
Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on the UnitedHealthcare Bilateral Eligible Procedures Policy List describe unilateral procedures that can be performed on both sides of the body during the same session by the Same Individual Physician or Other Qualified Health Care Professional. CPT or HCPCS codes with bilateral in their intent or with bilateral written in their description should not be reported with the bilateral modifier 50, or modifiers LT and RT, because the code is inclusive of the Bilateral Procedure. For the purpose of this policy, the Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.
What is a 1500 claim form?
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals.
What is the Physician Fee Schedule Payment Policy Indicator file layout?
The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used to identify endoscopic base codes, payment policy indicators, global surgery indicators or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.
What is Medicare Administrative Contractor?
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.