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). Modifier 50 applies to bilateral procedures performed on both sides of the body …
Can ASC bill for DME?
Feb 12, 2020 · For Medicare billing purposes, such procedures should be reported as a single line item. (NOTE: This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.) A procedure that is identified by its descriptor as a bilateral procedure (or unilateral or bilateral), as in codes 27395 and 52290 listed above, requires the …
How does Medicare affect medical billing?
Jul 19, 2016 · Answer: As of April 2013, Medicare Part B requires all bilateral surgical procedures to be submitted as a single line 67145 -50 with a 1 in the unit field and double the charge. Medicare will pay 150 percent of the allowable.
What are the requirements for Medicare billing?
Oct 01, 2013 · Health Insurance Claim Form 1500 Line 2: Enter CPT code 19303 with modifier 50 (bilateral procedure) in the “Procedures, Services, or Supplies” field (Box 24D). Also enter 1 in the “Days or Units” field (Box 24G). In this scenario there is no need to double the charge. Bill 100 percent on each line.
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How do I bill Medicare 20610 bilateral?
Place the CPT code 20610 in item 24D. If the drug was administered bilaterally, a -50 modifier should be used with 20610.Jan 1, 2012
What modifier is used for bilateral procedure?
Use 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).Nov 7, 2014
What is the bilateral procedure rule?
CMS defines a bilateral service as one in which the same procedure is performed on both sides of the body during the same operative session or on the same day.
How do you bill multiple procedures?
When billing, recommended practice is to list the highest-valued procedure performed, first, and to append modifier 51 to the second and any subsequent procedures. In practice, most billing software, and most payers, automatically will list billed codes from most-to-least valued.Dec 17, 2018
Does Medicare accept the 50 modifier?
Medicare will allow 100% of the highest paying surgical procedure on the claim plus 50% for the other ASC-covered surgical procedures furnished in the same session.
What is the correct CPT modifier for bilateral procedures?
CPT Modifier 50Bilateral services are procedures performed on both sides of the body during the same operative session or on the same day.
Can you bill modifier 50 and 26 together?
When modifier 50 is included in the medical claim, it can render certain other modifiers invalid (such as 26, LT, RT, and TC).Nov 26, 2019
How do you bill bilateral procedures to BCBS?
Bilateral procedures should be listed on the claim as a single line item, with modifier -50 and a two in the units field.” to Modifier -50 should be used for bilateral procedures. Bilateral procedures should be listed on the claim as a single line item, with modifier -50.”
How do you bill bilateral procedures for Unitedhealthcare?
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.
What is modifier 90 used for?
Modifier 90 is used when laboratory procedures are performed by a party other than the treating or reporting physician and the laboratory bills the physician for the service. For example, the physician (in his office) orders a CBC, the physician draws the blood and sends the specimen to an outside laboratory.Nov 20, 2019
How Does Medicare pay multiple procedures?
Payment methodologies for surgical procedures account for the overlap of the pre-procedure and post-procedure work. Under the so-called “multiple procedure rule,” Medicare pays less for the second and subsequent procedures performed during the same patient encounter.Mar 1, 2018
When should modifier 22 be used?
Modifier 22 is used for increased procedural services and demonstrates when a physician has gone above and beyond the typical framework of a particular procedure.
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
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.
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.
Why is coding for bilateral procedures so challenging?
Furthermore, coding for bilateral procedures is particularly challenging because it is defined in various ways.
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” ...
What is LT modifier?
Specifically, modifiers LT and RT should be used to identify procedures that can be performed on contralateral anatomic sites (such as bones, joints), paired organs (such as ears, eyes, nasal passages, kidneys, lungs, ovaries), or extremities (such as arms or legs). Modifiers LT and RT should be used to indicate that the procedure is performed on ...
When to use modifier LT?
In those instances, the modifier LT or RT is used to indicate the side of the body on which a service or procedure is performed.
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.
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.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Purified natural hyaluronates have been approved by the FDA for the treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond to simple analgesics or conservative nonpharmacologic therapy.
ICD-10-CM Codes that Support Medical Necessity
Note: Diagnosis codes must be coded to the highest level of specificity.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1833 (e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period..
Article Guidance
This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35004 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. Please refer to the LCD for reasonable and necessary requirements. Coding Guidance
ICD-10-CM Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.
ICD-10-CM Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this policy.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
