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August 6, 2013

CPT Modifier 50

Description:

Bilateral procedure

Guidelines/Instructions:

Refer to the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 50 is applicable to a particular procedure code.

• Do not submit CPT modifier 50 on procedures for midline organs such as the bladder, uterus, esophagus and nasal septum
• If a (subsequent) bilateral procedure requires a return to the operating room after the initial surgery, and the bilateral indicator in the MPFSDB is 1 or 2, do not submit CPT modifier 50. CPT modifiers 50 and 78 cannot be submitted for the same service. Instead, submit the surgery procedure code with CPT modifier 78 and HCPCS modifier RT on one detail line, and submit the same surgery procedure code with CPT modifier 78 and HCPCS modifier LT on a separate detail line.

Steps:

• Access the database directly from the CMS website
  • Select Physician Fee Schedule Search from the bottom of the web page
  • Screen defaults to current year. Under Type of Information, select Payment Policy Indicators.
  • Choose a single procedure code, multiple procedure codes or a range of codes, then enter the appropriate code(s)
  • Select modifier (or select 'all modifiers')
  • Refer to the column heading 'BILT SURG'

Indicator 0:

The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator '0' with HCPCS modifier RT or LT or CPT modifier 50. Submission of these modifiers may result in a denial. Payment will be based on the lower of the actual charge for both sides or 100 percent of the fee schedule amount for a single code. The bilateral adjustment is not appropriate for codes with Indicator '0' because of (a) physiology or anatomy, or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for a bilateral procedure.

Indicator 1:

The 150 percent adjustment for bilateral procedures applies. Bilateral procedures must be reported with CPT modifier 50 and a quantity of '1'. When the code is reported with CPT modifier 50, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other 'multiple procedure' rules. Submission of modifiers other than 50 may result in a denial.

Indicator 2:

The 150 percent adjustment for bilateral procedures does not apply. Do not submit codes with bilateral indicator 2 with HCPCS modifier RT or LT or CPT modifier 50. The Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charges by the physician for both sides or 100 percent of the fee schedule amount for a single code. If codes with bilateral indicator 2 are submitted with HCPCS modifier RT or LT or CPT modifier 50, the claim will be rejected as a 'billing error.' These claims must be corrected and resubmitted as new claims.

Indicator 3:

The 150 percent adjustment for bilateral procedures does not apply. Payment will be based on the lower of 100 percent of the fee schedule for each side or actual charges for each side. Report bilateral procedures with CPT modifier 50 and a quantity of '2' or report on separate detail lines with HCPCS modifiers RT and LT. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.

Indicator 9:

Concept does not apply. This indicator often appears in the CO SURG column for nonsurgical procedures.

Reference:

• Complete definitions of bilateral indicators are available in CMS Pub. 100-04, Chapter 23 (PDF, 1.38 MB), in the Addendum following Section 90

HCPCS Modifier LT

Description:

Left side (used to identify procedures performed on the left side of the body)

Guidelines/Instructions:

Refer to the Medicare Physician Fee Schedule database (MPFSDB) to determine if HCPCS modifier LT is applicable to a particular procedure code.

Steps:

• Access the database directly from the CMS website
• Select Physician Fee Schedule Search from the left area of the web page
• Screen defaults to current year. Under Type of Information, select Payment Policy Indicators, then 'next.'
• On the 'select field options' screen, select 'Next'
• Enter the procedure code and select 'All Modifiers', then click 'Submit'
• Refer to the column heading 'BILT SURG'

Indicator 0:

HCPCS modifier LT can be submitted with these codes. The 150 percent adjustment for bilateral procedures does not apply. Payment will be based on the lower of the actual charge for both sides or 100 percent of the fee schedule amount for a single code. The bilateral adjustment is not appropriate for codes with Indicator '0' 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 a bilateral procedure.

Indicator 1:

HCPCS modifier LT cannot be submitted with these codes. The 150 percent adjustment for bilateral procedures applies. The code must be reported with CPT modifier 50. When the code is reported with CPT modifier 50, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other 'multiple procedure rules.’ Submission of modifiers other than CPT modifier 50 may result in a denial.

Indicator 2:

The 150 percent adjustment for bilateral procedures does not apply. The Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charges by the physician for both sides, or 100 percent of the fee schedule amount for a single code. If codes with bilateral indicator 2 are submitted with HCPCS modifier RT or LT or CPT modifier 50, the claim will be rejected as a 'billing error' (remark code MA130). These claims must be corrected and resubmitted as new claims. If the procedure is performed on only the left side of the body, submit the service with CPT modifier 52 (refer to separate instructions for CPT modifier 52).

Reference:

• Complete definitions of MPFSDB indicators are available in CMS Pub. 100-04, Chapter 23, Section 30.2.2

HCPCS Modifier RT

Description:
Right side (used to identify procedures performed on the right side of the body)

Guidelines/Instructions:
Refer to the Medicare Physician Fee Schedule database (MPFSDB) to determine if HCPCS modifier RT is applicable to a particular procedure code.

Steps:

• Access the database directly from the CMS website
• Select Physician Fee Schedule Search from the left area of the web page
• Screen defaults to current year. Under Type of Information, select Payment Policy Indicators, then 'Next'.
• On the 'select field options' screen, select 'Next'
• Enter the procedure code and select 'All Modifiers', then click 'Update Results'
• On the right side select 'Show All Columns'
• Scroll to the right and refer to the column heading 'BILT SURG'
• Indicator 0: HCPCS modifier RT can be submitted with these codes. The 150 percent adjustment for bilateral procedures does not apply. Payment will be based on the lower of the actual charge for both sides or 100 percent of the fee schedule amount for a single code. The bilateral adjustment is not appropriate for codes with Indicator '0' because of (a) physiology or anatomy, or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for a bilateral procedure.

Indicator 1:

HCPCS modifier RT cannot be submitted with these codes. The 150 percent adjustment for bilateral procedures applies. The code must be reported with CPT modifier 50. When the code is reported with CPT modifier 50, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other 'multiple procedure' rules. Submission of modifiers other than 50 may result in a denial.

Indicator 2:

The 150 percent adjustment for bilateral procedures does not apply. The Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charges by the physician for both sides or 100 percent of the fee schedule amount for a single code. If codes with bilateral indicator 2 are submitted with HCPCS modifier RT or LT or CPT modifier 50, the claim will be rejected as a 'billing error' (remark code MA130) These claims must be corrected and resubmitted as new claims. If the procedure is performed on only the right side of the body, submit the service with CPT modifier 52 (refer to separate instructions for CPT modifier 52).

Reference:

• Complete definitions of MPFSDB indicators are available in CMS Pub. 100-04, chapter 23, section 30.2.2