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Added line is this color Deleted line is this color +<strong><a href= +"http://www.palmettogba.com/palmetto/providers.nsf/44197232fa85168985257196006939dd/85256d580043e75485257171006730d7?OpenDocument"> +Bilateral Surgeries and CPT Modifier 50</a></strong><br> +<p><b>Background</b><br> +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.</p> +<ul type="disc"> +<li>The “bilateral surgery indicator” in the MPFSDB indicates how the bilateral +surgery must be submitted to Medicare.</li> +<li>To access this database, refer to the CMS Web site at: <u><a href= +"http://www.cms.hhs.gov/Pfslookup"><font color= +"#0000FF">http://www.cms.hhs.gov/Pfslookup</font></a></u>.</li> +<li>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.</li> +</ul> +<p> </p> +<p><strong>Bilateral Surgery Indicators and Claim Submission</strong></p> +<table title="Bilateral Surgery Indicators and Claim Submission" border="1"> +<tbody> +<tr valign="top"> +<td scope="col" width="79" bgcolor="#E0F1FF"> +<div align="center"><strong>Bilateral Surgery Indicator</strong></div> +</td> +<td scope="col" width="314" bgcolor="#E0F1FF"> +<div align="center"><b>Payment Basis</b></div> +</td> +<td scope="col" width="197" bgcolor="#E0F1FF"> +<div align="center"><b>Claim Submission</b></div> +</td> +</tr> +<tr valign="top"> +<td width="79"> +<div align="center">0</div> +</td> +<td width="314">The lower of the actual submitted charge for both procedures +<i>or</i> 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.</td> +<td width="197">Submit the surgery with a quantity of “1.”<br> +<br> +Do <b>not</b> submit these procedures with CPT modifier 50.</td> +</tr> +<tr valign="top"> +<td width="79"> +<div align="center">1</div> +</td> +<td width="314">The lower of the actual submitted charge <i>or</i> 150% of the +fee schedule amount.</td> +<td width="197">Submit the surgery on a single detail line with CPT modifier 50 +and a quantity of “1.” <i>Option</i>: submit the surgery on 2 detail lines, one +with HCPCS modifier RT and one with HCPCS modifier LT. Tip: check any +applicable Local Coverage Determinations (LCDs) for additional information on +HCPCS modifiers RT and LT.</td> +</tr> +<tr valign="top"> +<td width="79"> +<div align="center">2</div> +</td> +<td width="314">The lower of the actual submitted charge for both procedures +<i>or</i> 100% of the fee schedule amount for a single procedure. The fee +schedule amount is already based on the procedure being performed +bilaterally.<br> +<br> +The fee schedule takes into account the bilateral nature of these procedures +because the code descriptor states that a) the procedure is bilateral, b) the +procedure may be performed unilaterally <i>or</i> bilaterally, or c) the +procedure is usually performed as a bilateral procedure.</td> +<td width="197">Submit the surgery with a quantity of “1.”<br> +<br> +Do <b>not</b> submit these procedures with CPT modifier 50.</td> +</tr> +<tr valign="top"> +<td width="79"> +<div align="center">3</div> +</td> +<td width="314">The lower of the actual submitted charge for both procedures +<i>or</i> 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.</td> +<td width="197">Submit the surgery (or procedure) on a single detail line with +CPT modifier 50 and a quantity of “2.” <i>Option</i>: submit the surgery on 2 +detail lines, one with HCPCS modifier RT and one with HCPCS modifier LT.</td> +</tr> +<tr valign="top"> +<td width="79"> +<div align="center">9</div> +</td> +<td width="314">The concept of “bilateral surgery” does not apply.</td> +<td width="197">Submit the surgery (or procedure) with a quantity of “1.”<br> +<br> +Do <b>not</b> submit these procedures with CPT modifier 50.</td> +</tr> +</tbody> +</table> +<p>Reference</p> +<ul type="disc"> +<li><a href= +"http://www.cms.hhs.gov/manuals">www.cms.hhs.gov/manuals/download/Clm104c12.pdf</a>: +CMS <i>Medicare Claims Processing Manual</i> (Pub. 100-04): Chapter 12, Section +40.7</li> +</ul> |