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Bilateral Surgeries

Bilateral Surgeries and CPT Modifier 50

Background
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.

The “bilateral surgery indicator” in the MPFSDB indicates how the bilateral surgery must be submitted to Medicare.
To access this database, refer to the CMS Web site at: http://www.cms.hhs.gov/Pfslookup.
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.

Bilateral Surgery Indicators and Claim Submission

Bilateral Surgery Indicator	Payment Basis	Claim Submission
0	The lower of the actual submitted charge for both procedures or 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.	Submit the surgery with a quantity of “1.” Do not submit these procedures with CPT modifier 50.
1	The lower of the actual submitted charge or 150% of the fee schedule amount.	Submit the surgery on a single detail line with CPT modifier 50 and a quantity of “1.” Option: 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.
2	The lower of the actual submitted charge for both procedures or 100% of the fee schedule amount for a single procedure. The fee schedule amount is already based on the procedure being performed bilaterally. 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 or bilaterally, or c) the procedure is usually performed as a bilateral procedure.	Submit the surgery with a quantity of “1.” Do not submit these procedures with CPT modifier 50.
3	The lower of the actual submitted charge for both procedures or 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.	Submit the surgery (or procedure) on a single detail line with CPT modifier 50 and a quantity of “2.” Option: submit the surgery on 2 detail lines, one with HCPCS modifier RT and one with HCPCS modifier LT.
9	The concept of “bilateral surgery” does not apply.	Submit the surgery (or procedure) with a quantity of “1.” Do not submit these procedures with CPT modifier 50.